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Wennberg P, Pakpour A, Broström A, Karlsson K, Magnusson C. Alfentanil for Pain Relief in a Swedish Emergency Medical Service - An Eleven-Year Follow-up on Safety and Effect. PREHOSP EMERG CARE 2024:1-6. [PMID: 38830199 DOI: 10.1080/10903127.2024.2363509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/25/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES Pain is a common symptom in prehospital emergency care and pain treatment in this context can be challenging. While previous research has assessed the use of morphine and other synthetic opioids for pain management in this setting, the evaluation of alfentanil is limited. The objective of this study was to evaluate the safety and effect of intravenous alfentanil when administered by ambulance nurses in prehospital emergency care. METHODS This retrospective observational study consecutively included patients suffering from pain, treated with alfentanil in a Swedish EMS service from September 2011 to 31 September 2022. Data regarding occurrence of adverse events (AE), serious adverse events (SAE) - were used for safety evaluation and pain scores with a visual analogue scale (VAS) before and after treatment were used for evaluation of pain treatment. These data were extracted from the electronic patients' medical records database for analysis. Univariate logistic regression analysis was used to identify significant predictors of AE following injection of alfentanil by nurses in prehospital emergency care. RESULTS During the evaluation period 17,796 patients received pain relief with alfentanil. Adverse events affected 2.5% of the patients, while serious adverse events were identified in 25 cases (0.01%). Out of the 5970 patients with a complete VAS score for pain, the median VAS score was 8 (IQR 3) before treatment and 4 (IQR 3) after treatment. The mean reduction in pain measured by VAS was -4.1 ± 2.6 from the time before, to the evaluation after alfentanil administration. The administration frequency increased during the first year up to a steady level during the later part of the evaluation period. CONCLUSIONS This study proposes that alfentanil represents a safe and efficacious alternative for addressing urgent pain relief within the prehospital emergency context. Alfentanil demonstrates efficacy in alleviating pain across various conditions, with a relatively low risk of adverse events or serious adverse events when administered cautiously.
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Affiliation(s)
- Pär Wennberg
- School of Health Sciences, Jönköping University, Jönköping, Sweden
- Ambulance Services, Skaraborg Hospital, Skövde, Sweden
| | - Amir Pakpour
- School of Health Sciences, Jönköping University, Jönköping, Sweden
| | - Anders Broström
- School of Health Sciences, Jönköping University, Jönköping, Sweden
- Department of Clinical Neurophysiology, Linköping University Hospital, Linköping, Sweden
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Vestlandet, Norway
| | - Kåre Karlsson
- Ambulance Services, Skaraborg Hospital, Skövde, Sweden
| | - Carl Magnusson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Deslandes M, Deicke M, Grannemann JJ, Hinkelbein J, Hoyer A, Kalmbach M, Kobiella A, Strickmann B, Plappert T, Jansen G. Effectiveness and safety of prehospital analgesia with nalbuphine and paracetamol versus morphine by paramedics - an observational study. Scand J Trauma Resusc Emerg Med 2024; 32:41. [PMID: 38730453 PMCID: PMC11084095 DOI: 10.1186/s13049-024-01215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/28/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Despite the development of various analgesic concepts, prehospital oligoanalgesia remains very common. The present work examines prehospital analgesia by paramedics using morphine vs. nalbuphine + paracetamol. METHODS Patients with out-of-hospital-analgesia performed by paramedics from the emergency medical services of the districts of Fulda (morphine) and Gütersloh (nalbuphine + paracetamol) were evaluated with regards to pain intensity at the beginning and the end of prehospital treatment using the Numeric-Rating-Scale for pain (NRS), sex, age, and complications. The primary endpoint was achievement of adequate analgesia, defined as NRS < 4 at hospital handover, depending on the analgesics administered (nalbuphine + paracetamol vs. morphine). Pain intensity before and after receiving analgesia using the NRS, sex, age and complications were also monitored. RESULTS A total of 1,808 patients who received out-of-hospital-analgesia were evaluated (nalbuphine + paracetamol: 1,635 (90.4%), NRS-initial: 8.0 ± 1.4, NRS-at-handover: 3.7 ± 2.0; morphine: 173(9.6%), NRS-initial: 8.5 ± 1.1, NRS-at-handover: 5.1 ± 2.0). Factors influencing the difference in NRS were: initial pain intensity on the NRS (regression coefficient (RK): 0.7276, 95%CI: 0.6602-0.7950, p < 0.001), therapy with morphine vs. nalbuphine + paracetamol (RK: -1.2594, 95%CI: -1.5770 - -0.9418, p < 0.001) and traumatic vs. non-traumatic causes of pain (RK: -0.2952, 95%CI: -0.4879 - -0.1024, p = 0.002). Therapy with morphine (n = 34 (19.6%)) compared to nalbuphine + paracetamol (n = 796 (48.7%)) (odds ratio (OR): 0.274, 95%CI: 0.185-0.405, p < 0.001) and the initial NRS score (OR:0.827, 95%CI: 0.771-0.887, p < 0.001) reduced the odds of having an NRS < 4 at hospital handover. Complications occurred with morphine in n = 10 (5.8%) and with nalbuphine + paracetamol in n = 35 (2.1%) cases. Risk factors for complications were analgesia with morphine (OR: 2.690, 95%CI: 1.287-5.621, p = 0.008), female sex (OR: 2.024, 95%CI: 1.040-3.937, p = 0.0379), as well as age (OR: 1.018, 95%CI: 1.003-1.034, p = 0.02). CONCLUSIONS Compared to morphine, prehospital analgesia with nalbuphine + paracetamol yields favourable effects in terms of analgesic effectiveness and a lower rate of complications and should therefore be considered in future recommendations for prehospital analgesia.
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Affiliation(s)
- Marvin Deslandes
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Martin Deicke
- Emergency Medical Service, County of Osnabrueck, Am Schölerberg 1, 49082, Osnabrueck, Germany
- Department of Anesthesiology and operative Intensive Care Medicine, Hospital of Osnabrueck, Am Finkenhügel 1, 49076, Osnabrueck, Germany
| | - Julia Johanna Grannemann
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Jochen Hinkelbein
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany
| | - Matthias Kalmbach
- Emergency Medical Services, City and District of Fulda, Otfrid-von-Weißenburg-Str. 3, 36043, Fulda, Germany
- Emergency Department, Klinikum Fulda, Pacelliallee 4, 36043, Fulda, Germany
| | - André Kobiella
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Bernd Strickmann
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Thomas Plappert
- Emergency Medical Services, City and District of Fulda, Otfrid-von-Weißenburg-Str. 3, 36043, Fulda, Germany
- Emergency Medical Services of the Order of Malta, Region Hesse, Schmidtstrasse 67, 60326, Frankfurt/Main, Germany
| | - Gerrit Jansen
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany.
- Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany.
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Scharonow O, Vilcane S, Weilbach C, Scharonow M. Analgesic Therapy with the Opioids Fentanyl and Morphine by Ambulance Personnel in Rural Areas: An Observational Study Over 7 Years. J Pain Res 2024; 17:345-355. [PMID: 38292758 PMCID: PMC10824613 DOI: 10.2147/jpr.s437131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/25/2023] [Indexed: 02/01/2024] Open
Abstract
Background The treatment of severe pain is one of the basic procedures of emergency medicine. In rural regions, longer arrival times of the emergency doctor prevent the earliest possible treatment of pain. Since 2014, a project for independent analgesia by ambulance personnel has been introduced in our ambulance service area. Methods Over a period of 7 years the mission protocols were recorded and statistically evaluated within the framework of an observational study. Among other things, the attendance and transport times, vital signs, pain level, symptom groups (body region) and classification according to disease or accident mechanism were recorded. Treatment data by medication, including dosages, were recorded for fentanyl (monotherapy), morphine (monotherapy) and a combination (change from morphine to fentanyl, additional application of esketamine, metamizole or butylscopolamine). Results In 659 patients, the opioids fentanyl and morphine were used by the ambulance staff, 596 data sets could be evaluated. When an emergency physician was requested, the average time of presence at the scene was 34.8 +- 11.7 min, in cases of unavailability it was 29.0 +-9.8 min (p<0.0001). Analgesic therapy resulted in a reduction of pain from NRS 8.4 (+-1.3) to NRS 3.5 +-1.8 (p<0.0001). Pain intensity after treatment by emergency paramedics compared to emergency physicians was not significantly different with NRS 3.5 +- 1.7 versus NRS 3.6 +-1.9 (p=0.788). Fentanyl was used at a mean dose of 0.18mg +- 0.11 and morphine at a mean dose of 4.4mg +- 3.6mg. There was no clinically relevant decrease in oxygen saturation or respiratory rate in any of the treatment groups. Antagonisation of the opioid effect with naloxone was not necessary in any case. Conclusion Analgesia with morphine and fentanyl by specially trained ambulance personnel according to defined rules of use is a safe and necessary procedure for patients, especially in rural regions.
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Affiliation(s)
- Olga Scharonow
- Department of Internal Medicine, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany
| | - Signe Vilcane
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany
| | - Christian Weilbach
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany
| | - Maximilian Scharonow
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany
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Rydlöv HS, Fjose LO, Heyerdahl F. Pain Management with Inhalation of Methoxyflurane Administrated by Non-Medical Ski Patrol: A Quality Assessment Study. Pain Ther 2023; 12:1455-1463. [PMID: 37578680 PMCID: PMC10616009 DOI: 10.1007/s40122-023-00547-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/21/2023] [Indexed: 08/15/2023] Open
Abstract
INTRODUCTION Pain management can be challenging, especially in remote locations where first responders are not certified health care personnel. In these settings, traditional intravenous administration of analgesics is not feasible. In this study, we explore the feasibility of using methoxyflurane as a first-line analgesic in ski-related traumas, administered by the ski patrol, acting as the municipality physician's aiding personnel. METHODS This is a quality assessment of a project aimed at improving pain management in trauma patients at the largest ski resort in Norway. Members of the ski patrol were trained and delegated administration of methoxyflurane on behalf of the municipality physician. Patients > 18 years with ski-related trauma and pain Numeric Rating Scale (NRS) of 6 or more were included. The patients received inhalational methoxyflurane on site, with continued administration during transport. Data were collected by the ski patrol and entered into a quality register. RESULTS In total, 53 patients (18 to 76 years, 32 (60%) males) accepted to be registered. The injuries were fractures in 35 (66%), joint luxation in seven (13%), combination of fracture and luxation in seven (13%), and blunt soft tissue damage in four (8%) cases. Median NRS before administration of methoxyflurane was 8 decreasing to median NRS 5 after 5-10 min. The median NRS reduction of 3 (25-75% percentiles 2-5) was significant, p < 0.001. Patients rated the perceived effect as good in 40 (80%) moderate in nine (18%) and no effect in 1 (2%). Side effects were mild: Six patients (11%) experienced dizziness, one patient (2%) was considered drowsy. CONCLUSIONS Methoxyflurane is feasible as a first-line analgesic administered by a non-medical ski patrol in a responsibly organized system. Early pain management with inhalation of methoxyflurane provides good perceived effect with mild adverse events and can be of great value in settings where few alternatives for pain management are available.
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Affiliation(s)
| | - Lars Olav Fjose
- Innlandet Health Trust, Division of Prehospital Services, Gjøvik, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Fridtjof Heyerdahl
- Norwegian Air Ambulance Foundation, Oslo, Norway.
- Air Ambulance Department, Oslo University Hospital, Oslo, Norway.
- University of Oslo, Institute of Clinical Medicine, Oslo, Norway.
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Strickmann B, Deicke M, Hoyer A, Kobiella A, Jansen G. Effectiveness and safety of prehospital analgesia including nalbuphine and paracetamol by paramedics: an observational study. Minerva Anestesiol 2023; 89:1105-1114. [PMID: 38019174 DOI: 10.23736/s0375-9393.23.17537-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND The aim of this study was to examine the effectiveness and safety of prehospital analgesia with nalbuphine and/or paracetamol by paramedics. METHODS In this retrospective trial, following the implementation of a standard-operating-procedure for pain requiring treatment as defined as a score ≥4 on the 0-10 Numeric Rating Scale for pain, all emergency operations in the district of Gütersloh between January 1, 2020, and June 30, 2022, with analgesic administration by paramedics in patients ≥18 years were included in the study. Analgesic agents employed by the paramedics included nalbuphine and/or paracetamol, butylscopolamine for abdominal colic, and esketamine in case of failure of the other analgesics. The primary endpoint was the patients' rating of their pain on the Numeric Rating Scale at the end of the operation. Additional covariates included sex, cause of pain, analgesics used, Numeric Rating Scale at beginning and analgesic-associated complications (reduced level of consciousness, hypotension, desaturation, a- or bradypnea). RESULTS A total of 1931 emergency operations (female: N.=1039 [53.8%]) with pain requiring treatment (non-traumatic cause: N.=1106 [57.3%]; initial Numeric Rating Scale: 8.0±1.4). Analgesics applied were nalbuphine + paracetamol (50.6%), paracetamol (38.7%), butylscopolamine (13.4%), nalbuphine (7.7%), and esketamine (4.9%). Mean pain reduction was 4.3±2.3 (nalbuphine + paracetamol: 5.0±2.1; nalbuphine: 4.7±2.3) and paracetamol: 3.3±2.2, respectively. Factors influencing a change in the Numeric Rating Scale were trauma (regression-coefficient: -0.308, 95% CI: -0.496 - -0.119, P=0.0014 vs. non-trauma; nalbuphine [yes vs. no]: regression-coefficient 0.684, 95% CI 0.0774-1.291, P=0.03; nalbuphine + paracetamol: regression-coefficient 0.763, 95% CI 0.227-1.299, P=0.005). At the end of the operation, 49.7% had a Numeric Rating Scale <4, 34.3% had a Numeric Rating Scale 4-5, and 16.0% had a Numeric Rating Scale ≥6. Factors influencing a Numeric Rating Scale <4 at end of use were trauma vs. non-trauma: odds ratio 0.788, 95% CI 0.649-0.957, P=0.02. The Numeric Rating Scale at beginning reported: odds ratios 0.754, 95% CI 0.700-0.812, P<0.0001. Analgesic-associated complications were not observed. CONCLUSIONS Prehospital analgesia by paramedics with nalbuphine as monotherapy or in combination with paracetamol allows for sufficient analgesia without the occurrence of complications.
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Affiliation(s)
| | | | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Bielefeld, Germany
| | | | - Gerrit Jansen
- Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Minden, Germany -
- Medical School OWL and University Medical Center OWL, Bielefeld University, Bielefeld, Germany
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Bielefeld, Germany
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Fichtner A, Schrofner-Brunner B, Magath T, Mutze P, Koch T. Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:815-822. [PMID: 37850298 PMCID: PMC10853923 DOI: 10.3238/arztebl.m2023.0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/19/2023]
Abstract
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.
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Affiliation(s)
| | | | - Tina Magath
- Deparment of Orthopedics and Trauma Surgery, Kreiskrankenhaus Freiberg
| | - Peik Mutze
- Deparment of Orthopedics and Trauma Surgery, Kreiskrankenhaus Freiberg
| | - Thea Koch
- Department of Anesthesiology and Critical Care Medicine of the University Hospital Carl Gustav Carus, TU-Dresden
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Vilcane S, Scharonow O, Weilbach C, Scharonow M. Application of analgesics in emergency services in Germany: a survey of the medical directors. BMC Emerg Med 2023; 23:104. [PMID: 37710177 PMCID: PMC10500886 DOI: 10.1186/s12873-023-00878-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
ABSTRAC BACKGROUND: Treatment of acute pain is an essential element of pre-hospital care for injured and critically ill patients. Clinical studies indicate the need for improvement in the prehospital analgesia. OBJECTIVE The aim of this study is to assess the current situation in out of hospital pain management in Germany regarding the substances, indications, dosage and the delegation of the use of analgesics to emergency medical service (EMS) staff. MATERIAL AND METHODS A standardized survey of the medical directors of the emergency services (MDES) in Germany was carried out using an online questionnaire. The anonymous results were evaluated using the statistical software SPSS (Chi-squared test, Mann-Whitney-U test). RESULTS Seventy-seven MDES responsible for 989 rescue stations and 397 EMS- physician bases in 15 federal states took part in this survey. Morphine (98.7%), Fentanyl (85.7%), Piritramide (61%), Sufentanil (18.2%) and Nalbuphine (14,3%) are provided as opioid analgesics. The non-opioid analgesics (NOA) including Ketamine/Esketamine (98,7%), Metamizole (88.3%), Paracetamol (66,2%), Ibuprofen (24,7%) and COX-2-inhibitors (7,8%) are most commonly available. The antispasmodic Butylscopolamine is available (81,8%) to most rescue stations. Fentanyl is the most commonly provided opioid analgesic for treatment of a traumatic pain (70.1%) and back pain (46.8%), Morphine for visceral colic-like (33.8%) and non-colic pain (53.2%). In cases of acute coronary syndrome is Morphine (85.7%) the leading analgesic substance. Among the non-opioid analgesics is Ketamine/Esketamine (90.9%) most frequently provided to treat traumatic pain, Metamizole for visceral colic-like (70.1%) and non-colic (68.6%) as well as back pain (41.6%). Butylscopolamine is the second most frequently provided medication after Metamizole for "visceral colic-like pain" (55.8%). EMS staff (with or without a request for presence of the EMS physician on site) are permitted to use the following: Morphine (16.9%), Piritramide (13.0%) and Nalbuphine (10.4%), and of NOAs for (Es)Ketamine (74.1%), Paracetamol (53.3%) and Metamizole (35.1%). The dosages of the most important and commonly provided analgesic substances permitted to independent treatment by the paramedics are often below the recommended range for adults (RDE). The majority of medical directors (78.4%) of the emergency services consider the independent application of analgesics by paramedics sensible. The reason for the relatively rare authorization of opioids for use by paramedics is mainly due to legal (in)certainty (53.2%). CONCLUSION Effective analgesics are available for EMS staff in Germany, the approach to improvement lies in the area of application. For this purpose, the adaptations of the legal framework as well as the creation of a guideline for prehospital analgesia are useful.
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Affiliation(s)
- Signe Vilcane
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
| | - Olga Scharonow
- Department of Internal Medicine, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Cloppenburg, Germany
| | - Christian Weilbach
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
| | - Maximilian Scharonow
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
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Simensen R, Fjose LO, Rehn M, Hagemo J, Thorsen K, Heyerdahl F. Comparison of three regimens with inhalational methoxyflurane versus intranasal fentanyl versus intravenous morphine in pre-hospital acute pain management: study protocol for a randomized controlled trial (PreMeFen). Trials 2023; 24:571. [PMID: 37670364 PMCID: PMC10478438 DOI: 10.1186/s13063-023-07590-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Pre-hospital pain management has traditionally been performed with intravenous (IV) morphine, but oligoanalgesia remain a recognized problem. Pain reduction is essential for patient satisfaction and is regarded as a measure of successful treatment. We aim to establish whether non-invasive methods such as inhalation of methoxyflurane is non-inferior to intranasal fentanyl or non-inferior to the well-known IV morphine in the pre-hospital treatment of acute pain. METHOD/DESIGN The PreMeFen study is a phase three, three-armed, randomized, controlled, non-inferiority trial to compare three regimens of analgesics: inhalation of methoxyflurane and intranasal (IN) fentanyl versus IV morphine. It is an open-label trial with a 1:1:1 randomization to the three treatment groups. The primary endpoint is the change in pain numeric rating scale (NRS) (0-10) from baseline to 10 min after start of investigational medicinal product administration (IMP). The non-inferiority margin was set to 1.3, and a sample size of 270 patients per protocol (90 in each treatment arm) will detect this difference with 90% power. DISCUSSION We chose a study design with comparison of analgesic regimens rather than fixed doses because of the substantial differences in drug characteristics and for the results to be relevant to inform policymakers in the pre-hospital setting. We recognize that easier administration of analgesics will lead to better pain management for many patients if the regimens are as good as the existing, and hence, we chose a non-inferiority design. The primary endpoint, the change in pain (NRS) after 10 min, is set to address the immediate need of pain reduction for patients with acute prehospital pain. On a later stage, more analgesic methods are often available. PreMeFen is a non-inferiority randomized controlled trial comparing three analgesic regimens aiming to establish whether inhalation of methoxyflurane or intranasal fentanyl is as good as IV morphine for fast reduction of acute pain in the prehospital setting.
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Affiliation(s)
- Randi Simensen
- Division of Pre-Hospital Services, Innlandet Hospital Trust, Kastbakkvegen 9, 2390, Moelv, Norway.
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Division of Pre-Hospital Services, Oslo University Hospital, Oslo, Norway.
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Lars Olav Fjose
- Division of Pre-Hospital Services, Innlandet Hospital Trust, Kastbakkvegen 9, 2390, Moelv, Norway
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Marius Rehn
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Pre-Hospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Hagemo
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Pre-Hospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjetil Thorsen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Fridtjof Heyerdahl
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Pre-Hospital Services, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Strandqvist E, Olheden S, Bäckman A, Jörnvall H, Bäckström D. Physician-staffed prehospital units: a retrospective follow-up from an urban area in Scandinavia. Int J Emerg Med 2023; 16:43. [PMID: 37452288 PMCID: PMC10349430 DOI: 10.1186/s12245-023-00519-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND The aim of this study was to determine when and how rapid response vehicles (RRVs) make a difference in prehospital care by investigating the number and kinds of RRV assignment dispatches and the prehospital characteristics and interventions involved. METHODS This retrospective cohort study was based on data from a quality assurance system where all assignments are registered. RRV staff register every assignment directly at the site, using a smartphone, tablet, or computer. There is no mandatory information requirement or time limit for registration. The study includes data for all RRVs operating in Region Stockholm, three during daytime hours and one at night - from January 1, 2021 to December 31, 2021. RESULTS In 2021, RRVs in Stockholm were dispatched on 11,283 occasions, of which 3,571 (31.6%) resulted in stand-downs. In general, stand-downs were less common for older patients. The most common dispatch category was blunt trauma (1,584 or 14.0%), which accounted for the highest frequency of stand-downs (676 or 6.0%). The second most common category was cardiac arrest (1,086 or 9.6%), followed by shortness of breath (691 or 6.1%), medical not specified (N/S) (596 or 5.3%), and seizures (572 or 5.1%). CONCLUSION The study findings confirm that RRVs provide valuable assistance to the ambulance service in Stockholm, especially for cardiac arrest and trauma patients. In particular, RRV personnel have more advanced medical knowledge and can administer medications and perform interventions that the regular ambulance service cannot provide.
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Affiliation(s)
| | - Staffan Olheden
- Capio Akutläkarbilar, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Department of Perioperative Care, Solna Karolinska University Hospital, Stockholm, Sweden
| | - Anders Bäckman
- Capio Akutläkarbilar, Stockholm, Sweden
- Center for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Henrik Jörnvall
- Capio Akutläkarbilar, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Department of Perioperative Care, Solna Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section for Anesthesia and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Denise Bäckström
- Capio Akutläkarbilar, Stockholm, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, 581 83 Linköping, Sweden
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10
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Whitley GA, Wijegoonewardene N, Nelson D, Curtis F, Ortega M, Siriwardena AN. Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis. J Am Coll Emerg Physicians Open 2023; 4:e12940. [PMID: 37056718 PMCID: PMC10086522 DOI: 10.1002/emp2.12940] [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] [Indexed: 04/15/2023] Open
Abstract
Background We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care. Methods A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated. Results Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey. Conclusion Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.
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Affiliation(s)
- Gregory Adam Whitley
- Community and Health Research UnitUniversity of LincolnLincolnUK
- Clinical Audit and Research UnitEast Midlands Ambulance Service NHS TrustLincolnUK
| | - Nimali Wijegoonewardene
- Community and Health Research UnitUniversity of LincolnLincolnUK
- Healthcare Quality and SafetyMinistry of HealthColomboSri Lanka
| | - David Nelson
- Lincoln International Institute for Rural HealthUniversity of LincolnLincolnUK
| | - Ffion Curtis
- Centre for Ethnic Health ResearchEast Midlands Applied Research CollaborationUniversity of LeicesterLeicesterUK
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Lindbeck G, Shah MI, Braithwaite S, Powell JR, Panchal AR, Browne LR, Lang ES, Burton B, Coughenour J, Crowe RP, Degn H, Hedges M, Gasper J, Guild K, Mattera C, Nasca S, Taillac P, Warth M. Evidence-Based Guidelines for Prehospital Pain Management: Recommendations. PREHOSP EMERG CARE 2023; 27:144-153. [PMID: 34928760 DOI: 10.1080/10903127.2021.2018073] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.
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Affiliation(s)
- George Lindbeck
- Office of Emergency Medical Services, Virginia Department of Health, and the Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Manish I Shah
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sabina Braithwaite
- Missouri Department of Health and Senior Services, Washington University in St Louis School of Medicine, St. Louis, Missouri, USA
| | - Jonathan R Powell
- National Registry of Emergency Medical Technicians (NREMT), Columbus, Ohio, USA
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians (NREMT), The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lorin R Browne
- Milwaukee County EMS, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Eddy S Lang
- Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada
| | - Brooke Burton
- Falck Ambulance Northern California, Petaluma, California, USA
| | - Jeffrey Coughenour
- iFrank Mitchell, Jr., MD, Trauma Center, University of Missouri Healthcare, Columbia, Missouri, USA
| | | | - Hannah Degn
- National Association of State EMS Officials (NASEMSO)
| | - Mary Hedges
- National Association of State EMS Officials (NASEMSO)
| | - James Gasper
- California Department of Health Care Services, Sacramento, California, USA
| | - Kyle Guild
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | | | - Peter Taillac
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mark Warth
- Colorado Springs Fire Department, Colorado Springs, Colorado, USA
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12
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Supples MW, Vaizer J, Liao M, Arkins T, Lardaro TA, Faris G, O'Donnell DP, Glober NK. Patient Demographics Are Associated with Differences in Prehospital Pain Management among Trauma Patients. PREHOSP EMERG CARE 2022; 27:1048-1053. [PMID: 36191334 DOI: 10.1080/10903127.2022.2132565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/01/2022] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
| | - Julia Vaizer
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark Liao
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Gregory Faris
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Nancy K Glober
- Indiana University School of Medicine, Indianapolis, Indiana
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Ferri P, Gambaretto C, Alberti S, Parogni P, Rovesti S, Di Lorenzo R, Sollami A, Bargellini A. Pain Management in a Prehospital Emergency Setting: A Retrospective Observational Study. J Pain Res 2022; 15:3433-3445. [PMID: 36324866 PMCID: PMC9621014 DOI: 10.2147/jpr.s376586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/23/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose Acute pain is a prevalent symptomatology in prehospital emergency care. Although inadequate assessment and treatment of acute pain are associated with various complications, about 43% of adults suffering from pain are undertreated. This phenomenon is poorly studied, and limited data are available in the literature. The objective was to investigate the pain management in a prehospital emergency health-care setting, verifying pain assessment, pharmacological treatment adherence and the effectiveness of pain relief therapy. Patients and Methods A retrospective observational study was conducted in a sample including all adults treated by the professionals of nurse-staffed ambulances and medical cars in an Italian Emergency Medical Services (EMS) from 1 January 2019 to 31 May 2019. We collected both demographic information and Numeric Rating Scale scores, which evaluated presence and intensity of pain, from the EMS paper forms. All analyses were performed using SPSS, version 27. Results The study sample was composed of 629 people: 310 males (49%) and 319 females (51%), with an average age of 64.2±22 years (range 18-108). Pain information was collected in 75.5% (n = 475) of our sample; among them 222 patients (46.7%) suffered from pain. We recorded that 79.7% (n = 177) of the subjects with pain received no pharmacological treatment, and in almost all of the treated cases they did not adhere to the analgesia algorithm in use. Among those who were pharmacologically treated, pain statistically significantly decreased in intensity, from before to after, in both emergency vehicles (nurse-staffed ambulances pre m = 8.36±0.9 vs post m = 4.18±2.2, p<0.001; medical cars pre m = 7.25±1.7 vs post m = 3.50±2.6, p<0.001). Subsequently, pain was only re-ascertained in 24.3% of subjects. Conclusion Our findings confirm that pain is a prevalent symptom in prehospital patients, especially in the younger age range, but that it remains an underrecognized, underestimated, and undertreated symptom with the risk of causing worse health outcomes.
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Affiliation(s)
- Paola Ferri
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Sara Alberti
- Clinical and Experimental Medicine PhD Program, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy,Correspondence: Sara Alberti, Clinical and Experimental Medicine PhD Program, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy, Tel +390592055599, Email
| | | | - Sergio Rovesti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Rosaria Di Lorenzo
- Department of Mental Health and Drug Abuse, AUSL of Modena, Modena, Italy
| | - Alfonso Sollami
- Health Professions Service, University Hospital of Parma, Parma, Italy
| | - Annalisa Bargellini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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14
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Aceves A, Crowe RP, Zaidi H, Gill J, Johnson R, Vithalani V, Fairbrother H, Huebinger R. Disparities in Prehospital Non-Traumatic Pain Management. PREHOSP EMERG CARE 2022:1-6. [PMID: 35939557 DOI: 10.1080/10903127.2022.2107122] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- Angie Aceves
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, Texas
| | | | - Hashim Zaidi
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, Texas
| | - Joseph Gill
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, Texas
| | - Renee Johnson
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, Texas
| | - Veer Vithalani
- Office of the Medical Director & MedStar Mobile Healthcare, Metropolitan Area EMS Authority, Fort Worth, TX.,JPS Health Network, Department of Emergency Medicine, Fort Worth, TX
| | - Hilary Fairbrother
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, Texas
| | - Ryan Huebinger
- McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Department of Emergency Medicine, Houston, Texas
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15
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The Influence of Gender Bias: Is Pain Management in the Field Affected by Health Care Provider's Gender? Prehosp Disaster Med 2022; 37:638-644. [PMID: 35924723 DOI: 10.1017/s1049023x2200111x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Appropriate pain management indicates the quality of casualty care in trauma. Gender bias in pain management focused so far on the patient. Studies regarding provider gender are scarce and have conflicting results, especially in the military and prehospital settings. STUDY OBJECTIVE The purpose of this study is to investigate the effect of health care providers' gender on pain management approaches among prehospital trauma casualties treated by the Israel Defense Forces (IDF) medical teams. METHODS This retrospective cohort study included all trauma casualties treated by IDF senior providers from 2015-2020. Casualties with a pain score of zero, age under 18 years, or treated with endotracheal intubation were excluded. Groups were divided according to the senior provider's gender: only females, males, or both female and male. A multivariate analysis was performed to assess the odds ratio of receiving an analgesic, depending on the presence of a female senior provider, adjusting for potential confounders. A subgroup analysis was performed for "delta-pain," defined as the difference in pain score during treatment. RESULTS A total of 976 casualties were included, of whom 835 (85.6%) were male. Mean pain scores (SD) for the female only, male only, and both genders providers were 6.4 (SD = 2.9), 6.4 (SD = 3.0), and 6.9 (SD = 2.8), respectively (P = .257). There was no significant difference between females, males, or both female and male groups in analgesic treatment, overall and per specific agent. This remained true also in the multivariate model. Delta-pain difference between groups was also not significant. Less than two-thirds of casualties in this study were treated for pain among all study groups. CONCLUSION This study found no association between IDF Medical Corps providers' gender and pain management in prehospital trauma patients. Further studies regarding disparities in acute pain treatment are advised.
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Smith MD, Rowan E, Spaight R, Siriwardena AN. Evaluation of the effectiveness and costs of inhaled methoxyflurane versus usual analgesia for prehospital injury and trauma: non-randomised clinical study. BMC Emerg Med 2022; 22:122. [PMID: 35799131 PMCID: PMC9261021 DOI: 10.1186/s12873-022-00664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/01/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We aimed to investigate clinical benefits and economic costs of inhaled methoxyflurane when used by ambulance staff for prehospital emergency patients with trauma. Comparison is to usual analgesic practice (UAP) in the UK in which patient records were selected if treatment had been with Entonox® or intravenous morphine or intravenous paracetamol. METHODS Over a 12-month evaluation period, verbal numerical pain scores (VNPS) were gathered from adults with moderate to severe trauma pain attended by ambulance staff trained in administering and supplied with methoxyflurane. Control VNPS were obtained from ambulance database records of UAP in similar patients for the same period. Statistical modelling enabled comparisons of methoxyflurane to UAP, where we employed an Ordered Probit panel regression model for pain, linked by observational rules to VNPS. RESULTS Overall, 96 trained paramedics and technicians from the East Midlands Ambulance Service NHS Trust (EMAS) prepared 510 doses of methoxyflurane for administration to a total of 483 patients. Comparison data extracted from the EMAS database of UAP episodes involved: 753 patients using Entonox®, 802 patients using intravenous morphine, and 278 patients using intravenous paracetamol. Modelling results included demonstration of faster pain relief with inhaled methoxyflurane (all p-values < 0.001). Methoxyflurane's time to achieve maximum pain relief was estimated to be significantly shorter: 26.4 min (95%CI 25.0-27.8) versus Entonox® 44.4 min (95%CI 39.5-49.3); 26.5 min (95%CI 25.0-27.9) versus intravenous morphine 41.8 min (95%CI 38.9-44.7); 26.5 min (95%CI 25.1-28.0) versus intravenous paracetamol 40.8 (95%CI 34.7-46.9). Scenario analyses showed that durations spent in severe pain were significantly less for methoxyflurane. Costing scenarios showed the added benefits of methoxyflurane were achieved at higher cost, eg versus Entonox® the additional cost per treated patient was estimated to be £12.30. CONCLUSION When administered to adults with moderate or severe pain due to trauma inhaled methoxyflurane reduced pain more rapidly and to a greater extent than Entonox® and parenteral analgesics. Inclusion of inhaled methoxyflurane to the suite of prehospital analgesics provides a clinically useful addition, but one that is costlier per treated patient.
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Affiliation(s)
- Murray D Smith
- Community and Health Research Unit, University of Lincoln, Lincoln, UK.
| | - Elise Rowan
- Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - Robert Spaight
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust, Nottingham, UK
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17
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Teoh SE, Loh CYL, Chong RIH, Yaow CYL, Masuda Y, Han MX, Lin DJ, Lim YL, Ng JCH, Ng QX. A scoping review of qualitative studies on pre-hospital analgesia administration and practice. Am J Emerg Med 2022; 57:81-90. [DOI: 10.1016/j.ajem.2022.04.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/26/2022] [Indexed: 01/08/2023] Open
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18
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Polish Experiences of Pain Treatment by Paramedics in relation to Good Practices of Pain Treatment: A Register-Based Study. Emerg Med Int 2022; 2022:3677688. [PMID: 35433049 PMCID: PMC9010201 DOI: 10.1155/2022/3677688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background Pain is frequently encountered in the prehospital setting. The treatment of pain is one of the priority activities for paramedics. Methods 1048576 patients under the care of EMS over a 7-month period were included in this study. Data included using pain scale and pain score, the initial diagnosis, analgesic treatment and the given drug obtained from the Ambulance Emergency Procedure Cards. Results The complete absence of pain was detected in 43.9% (95% CI 43.8–44.0) of patients, mild pain in 17.0% (95% CI 16.9–17.1), moderate pain in 11.6% (95% CI 11.5–11.7), and severe pain in 4.9% (95% CI 4.9–4.9) of cases. In 22.5% (95% CI 22.4–22.6), no pain rating scale was used. 98.0% (95% CI 97.9–98.1) of patients with mild, 96.1% (95% CI 96.0–96.2) with moderate, and 94.0% (95% CI 93.9–94.1) with severe pain did not receive any pain medication. The most commonly used drugs in all groups were metamizole and ketoprofen. The greatest analgesic effect was observed in the group of patients with severe pain. Pain decreased by an average of 3.2 NRS points in the drug-free group and 3.1 NRS points in the treated group. The most commonly documented diagnoses in all groups of patients were signs and diseases not classified in other groups (ICD-10 R00-R99), injuries and consequences of external causes (ICD-10 S00-T98), and diseases of the circulatory system (ICD-10 I00–I99). Conclusions Paramedics may use a variety of medications but use them rarely. Adding metamizole to the list of medications used by paramedics has made it one of the most commonly used drugs. Regardless of whether the drug was used or not, the analgesic effect was similar.
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19
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Gaither JB, Rice AD, Jado I, Armstrong S, Packard SE, Clark J, Draper S, Duncan M, Bradley B, Spaite DW. Impact of In-Station Medication Automated Dispensing Systems On Prehospital Pain Medication Administration. PREHOSP EMERG CARE 2022; 27:350-355. [PMID: 35191770 DOI: 10.1080/10903127.2022.2045405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Introduction: Medication automatic dispensing systems (ADS) have been implemented in many settings, including fire-based EMS stations. The aim of this study was to evaluate the impact of in-station ADSs on controlled substance administration rates and EMS response intervals.Methods: This study was a retrospective review of data from a single fire-based EMS agency. Medication administration rates and EMS response intervals were compared before ADS implementation (P1; 6/1/15 to 5/31/16) and after ADS implementation (P3; 6/1/17-5/31/19). Cases with missing data and during a one-year implementation period were excluded.Results: 4045 cases were identified in P1 and 8168 in P3. The odds of morphine or versed administration increased following ADS implementation: OR =1.77 (95% CI: 1.53, 2.03) and OR =1.53 (95%CI: 1.18, 2.00) respectively. There were statistically, but likely not operationally significant increases in median response interval and transport interval from P1 to P3 of 14 seconds, (p < 0.001) and 39 seconds (p< 0.001) respectively. Time at hospital for all calls decreased by more than 11 minutes for all transports, from a median of 34 minutes (IQR; 23.7, 45.5) to 22.7 minutes (IQR:18.5, 27.6) in P3, p < 0.001 and by 27.9 minutes for calls in which a controlled substance was given: P1 = 50.6 minutes (IQR: 34.6, 63.2), P3 = 22.7 minutes (IQR: 18.3, 27.4), p < 0.001.Conclusion: In this system, medication ADS implementation was associated with an increase in the rates of controlled substance administration and a decrease in the time units were at hospitals.
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Affiliation(s)
- Joshua B Gaither
- Arizona Emergency Medicine Research Center, Tucson, AZ.,Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Amber D Rice
- Arizona Emergency Medicine Research Center, Tucson, AZ.,Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.,Northwest Fire District, Tucson, AZ
| | - Isrealia Jado
- Arizona Emergency Medicine Research Center, Tucson, AZ.,Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Smita Armstrong
- Arizona Emergency Medicine Research Center, Tucson, AZ.,Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.,University of Arizona, College of Medicine, Tucson, AZ
| | - Samuel E Packard
- Columbia University Mailman School of Public Health, New York, NY
| | | | | | | | | | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, Tucson, AZ.,Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.,Northwest Fire District, Tucson, AZ
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Friesgaard KD, Vist GE, Hyldmo PK, Raatiniemi L, Kurola J, Larsen R, Kongstad P, Magnusson V, Sandberg M, Rehn M, Rognås L. Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review. Pain Ther 2022; 11:17-36. [PMID: 35041151 PMCID: PMC8861251 DOI: 10.1007/s40122-021-00346-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/10/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies. METHODS The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method. RESULTS A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine. CONCLUSIONS Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.
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Affiliation(s)
- Kristian Dahl Friesgaard
- Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus, Denmark. .,Department of Anaesthesiology, Regional Hospital of Horsens, Horsens, Denmark. .,Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Gunn Elisabeth Vist
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Per Kristian Hyldmo
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.,Trauma Unit, Sørlandet Hospital, Kristiansand, Norway
| | - Lasse Raatiniemi
- Centre for Prehospital Emergency Care, Oulu University Hospital, Oulu, Finland.,Anaesthesia Research Group, MRC, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Jouni Kurola
- Centre for Prehospital Emergency Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Robert Larsen
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Poul Kongstad
- Department of Prehospital Care and Disaster Medicine, Region of Skåne, Lund, Sweden
| | | | - Mårten Sandberg
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
| | - Marius Rehn
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.,Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
| | - Leif Rognås
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Air Ambulance, Aarhus, Denmark
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21
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Abebe Y, Hetmann F, Sumera K, Holland M, Staff T. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29:170. [PMID: 34895311 PMCID: PMC8665507 DOI: 10.1186/s13049-021-00974-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinically meaningful pain reduction with respect to severity and the adverse events of drugs used in prehospital pain management for children are areas that have not received sufficient attention. The present systematic review therefore aims to perform a comprehensive search of databases to examine the preferable drugs for prehospital pain relief in paediatric patients with acute pain, irrespective of aetiology. METHODS The systematic review includes studies from 2000 and up to 2020 that focus on children's prehospital pain management. The study protocol is registered in PROSPERO with registration no. CRD42019126699. Pharmacological pain management using any type of analgesic drug and in all routes of administration was included. The main outcomes were (1) measurable pain reduction (effectiveness) and (2) no occurrence of any serious adverse events. Searches were conducted in PubMed, Medline, Embase, CINAHL, Epistemonikos and Cochrane library. Finally, the risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist and a textual narrative analysis was performed due to the heterogeneity of the results. RESULTS The present systematic review on the effectiveness and safety of analgesic drugs in prehospital pain relief in children identified a total of eight articles. Most of the articles reviewed identified analgesic drugs such as fentanyl (intranasal/IV), morphine (IV), methoxyflurane (inhalational) and ketamine (IV/IM). The effects of fentanyl, morphine and methoxyflurane were examined and all of the included analgesic drugs were evaluated as effective. Adverse events of fentanyl, methoxyflurane and ketamine were also reported, although none of these were considered serious. CONCLUSION The systematic review revealed that fentanyl, morphine, methoxyflurane and combination drugs are effective analgesic drugs for children in prehospital settings. No serious adverse events were reported following the administration of fentanyl, methoxyflurane and ketamine. Intranasal fentanyl and inhalational methoxyflurane seem to be the preferred drugs for children in pre-hospital settings due to their ease of administration, similar effect and safety profile when compared to other analgesic drugs. However, the level of evidence (LOE) in the included studies was only three or four, and further studies are therefore necessary.
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Affiliation(s)
- Yonas Abebe
- Department of Emergency and Critical Care Nursing, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway.
| | - Fredrik Hetmann
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
| | | | - Matt Holland
- Library and Knowledge Services for NHS Ambulance Services in England, Bolton, UK
| | - Trine Staff
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
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22
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Imbriaco G, Rondelli R, Maroni F, Mazzolani S, Sasso S, Sebastiani S, Samolsky Dekel BG. Nurse-Administered Analgesic Treatment in Italian Emergency Medical Services: A Nationwide Survey. J Pain Res 2021; 14:1827-1835. [PMID: 34163237 PMCID: PMC8215928 DOI: 10.2147/jpr.s303998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background Acute pain is common among patients requiring assistance from prehospital emergency medical services (EMS). Nonetheless, the undertreatment of pain in this context remains a frequent phenomenon. Timely and effective analgesia is a crucial feature in emergency medicine. To ensure analgesia provision, prehospital paramedics and nurses can administer analgesics via standard operating protocols or under a physician’s remote supervision. Information about such protocols in Italian EMS is lacking. Objective Evaluation of the availability of nurse’s standard analgesia protocols in Italy’s prehospital EMS settings. Methods A cross-sectional online survey involved all 74 Italian emergency medical dispatch centres (EMDCs). Aside from descriptive statistics, we used χ2-analysis and Spearman-rank correlation to look for associations between geographical areas’ dependence upon independent variable categories and their correlations. Results Of all the 74 Italian EMDCs, 70 (94.6%) completed the survey, covering 100 provinces out of a total of 107 (93.5%). Operating nurses’ prehospital analgesia protocols are available in 46 provinces (46.0%). The availability of prehospital analgesia protocols is more extended in northern Italy EMDCs (n=30, 66.7%) than in central Italy (n=9, 42.8%) and southern Italy and islands (n=7, 20.6%). Morphine (76.1% for medical patients and 95.7% for trauma) and paracetamol (89.1% for both) are the most common drugs included in the prehospital analgesia protocols. Conclusion Despite international consensus on the necessity, efficacy, and safety of nurses’ prehospital analgesia provision, nurse-administered analgesia protocols are available in less than half of Italian provinces, with substantial differences between northern, central, and southern areas. These results indirectly indicate potential undertreatment of prehospital pain in Italy and yield practice improvements.
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Affiliation(s)
- Guglielmo Imbriaco
- Centrale Operativa 118 Emilia Est, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy.,Critical Care Nursing Master Course, University of Bologna, Bologna, Italy
| | - Riccardo Rondelli
- Intensive Care Unit, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Federica Maroni
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,Emergency Department, Bufalini Hospital, Cesena, Italy
| | - Selene Mazzolani
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,Intensive Care Unit, Infermi Hospital, Faenza, Italy
| | - Silvia Sasso
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,Surgical Unit, State Hospital, San Marino, San Marino Republic
| | - Stefano Sebastiani
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Boaz Gedaliahu Samolsky Dekel
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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23
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Magnusson C, Carlström M, Lidman N, Herlitz J, Wennberg P, Axelsson C. Evaluation and treatment of pain in the pre-hospital setting. A comparison between patients with a hip injury, chest pain and abdominal pain. Int Emerg Nurs 2021; 56:100999. [PMID: 33765527 DOI: 10.1016/j.ienj.2021.100999] [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: 08/03/2020] [Revised: 02/19/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND A large proportion of patients who call 112 in Sweden do so because of pain. The purpose of this study was to compare three of the most common types of pain presented by the patients: chest pain, abdominal pain and hip injury, in terms of initial assessment, intensity, treatment and effect of treatment. The overall rationale was to evaluate whether the early assessment and treatment of pain in the pre-hospital setting is optimal or whether there is room for improvement. METHODS Observational study during 2016 including 1234 patients triaged to chest pain, abdominal pain and hip injury by the Emergency Medical Services (EMS) in Gothenburg, Sweden. RESULTS Severe pain on the arrival of the EMS was described by 39% of patients with a hip injury, 27% with abdominal pain and 15% with chest pain. Analgesics were given to 58% of patients with a hip injury, 35% with chest pain and 34% with abdominal pain. A lower intensity of pain at re-evaluation was observed in 80% of patients with a hip injury, 57% with chest pain and 43% with abdominal pain. Administration of analgesics increased with the duration of pre-hospital care time in all three groups. CONCLUSIONS Patients with a hip injury had the most severe pain and they received most pain-relieving medication. Overall, a relatively small proportion of patients with pain received pain-relieving medication and there appears to be an extensive room for improvement.
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Affiliation(s)
- Carl Magnusson
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Prehospen - Centre for Prehospital Research, University of Borås, Sweden; Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie Carlström
- Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nathalie Lidman
- Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Herlitz
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Prehospen - Centre for Prehospital Research, University of Borås, Sweden.
| | - Pär Wennberg
- Prehospen - Centre for Prehospital Research, University of Borås, Sweden; Research and Development Centre, Skaraborg Hospital, Skövde, Sweden
| | - Christer Axelsson
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Prehospen - Centre for Prehospital Research, University of Borås, Sweden; Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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Abstract
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.
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25
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Rugg C, Woyke S, Voelckel W, Paal P, Ströhle M. Analgesia in adult trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis. Scand J Trauma Resusc Emerg Med 2021; 29:28. [PMID: 33526048 PMCID: PMC7852148 DOI: 10.1186/s13049-021-00839-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/18/2021] [Indexed: 11/14/2022] Open
Abstract
Background Sufficient analgesia is an obligation, but oligoanalgesia (NRS> 3) is frequently observed prehospitally. Potent analgesics may cause severe adverse events. Thus, analgesia in the helicopter emergency medical service (HEMS) setting is challenging. Adequacy, efficacy and administration safety of potent analgesics pertaining to injured patients in HEMS were analysed. Methods Observational study evaluating data from 14 year-round physician-staffed helicopter bases in Austria in a 12-year timeframe. Results Overall, 47,985 (34.3%) patients received analgesics, 26,059 of whom were adult patients, injured and not mechanically ventilated on site. Main drugs administered were opioids (n=20,051; 76.9%), esketamine (n=9082; 34.9%), metamizole (n=798; 3.1%) and NSAIDs (n=483; 1.9%). Monotherapy with opioids or esketamine was the most common regimen (n=21,743; 83.4%), while opioids together with esketamine (n= 3591; 13.8%) or metamizole (n=369; 1.4%) were the most common combinations. Females received opioids less frequently than did males (n=6038; 74.5% vs. n=14,013; 78.1%; p< 0.001). Pain relief was often sufficient (> 95%), but females more often had moderate to severe pain on arrival in hospital (n=34; 5.0% vs. n=59; 3.2%; p=0.043). Administration of potent analgesics was safe, as indicated by MEES, SpO2 and respiratory rates. On 10% of all missions, clinical patient assessment was deemed sufficient by HEMS physicians and monitoring was spared. Conclusions Opioids and esketamine alone or in combination were the analgesics of choice in physician-staffed HEMS in Austria. Analgesia was often sufficient, but females more than males suffered from oligoanalgesia on hospital arrival. Administration safety was high, justifying liberal use of potent analgesics in physician-staffed HEMS. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00839-9.
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Affiliation(s)
- Christopher Rugg
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Simon Woyke
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Wolfgang Voelckel
- Department of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr.-Franz-Rehrl-Platz 5, 5010, Salzburg, Austria
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Kajetanerplatz 1, 5010, Salzburg, Austria.,Austrian Society for Mountain and High-altitude Medicine (ÖGAHM), Lehnrain 30a, 6414, Mieming, Austria
| | - Mathias Ströhle
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria. .,Austrian Society for Mountain and High-altitude Medicine (ÖGAHM), Lehnrain 30a, 6414, Mieming, Austria.
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Eccleston C, Fisher E, Howard RF, Slater R, Forgeron P, Palermo TM, Birnie KA, Anderson BJ, Chambers CT, Crombez G, Ljungman G, Jordan I, Jordan Z, Roberts C, Schechter N, Sieberg CB, Tibboel D, Walker SM, Wilkinson D, Wood C. Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:47-87. [PMID: 33064998 DOI: 10.1016/s2352-4642(20)30277-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Christopher Eccleston
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK; Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium.
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Bath, UK; Cochrane Pain, Palliative, and Supportive Care Review Groups, Churchill Hospital, Oxford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rebeccah Slater
- Department of Paediatrics, University of Oxford, Oxford, UK; Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Paula Forgeron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, ON, Canada
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kathryn A Birnie
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, AB, Canada
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Christine T Chambers
- Department of Psychology and Neuroscience, and Department of Pediatrics, Dalhousie University, Halifax, NS, Canada; Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Geert Crombez
- Department of Clinical-Experimental and Health Psychology, Ghent University, Ghent, Belgium
| | - Gustaf Ljungman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | | | - Neil Schechter
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
| | - Christine B Sieberg
- Division of Pain Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Suellen M Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; John Radcliffe Hospital, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Chantal Wood
- Department of Spine Surgery and Neuromodulation, Poitiers University Hospital, Poitiers, France
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Raatiniemi L, Magnusson V, Hyldmo PK, Friesgaard KD, Kongstad P, Kurola J, Larsen R, Rehn M, Rognås L, Sandberg M, Vist GE. Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis. Acta Anaesthesiol Scand 2020; 64:1038-1047. [PMID: 32270488 DOI: 10.1111/aas.13600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting. METHODS A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments. RESULTS Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine. CONCLUSIONS Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.
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Affiliation(s)
- Lasse Raatiniemi
- Centre for Prehospital Emergency Care Oulu University Hospital Oulu Finland
- Anaesthesia Research group MRC Oulu University Hospital and University of Oulu Oulu Finland
| | - Vidar Magnusson
- Prehospital section and Department of Anaesthesia Landspitalinn University Hospital Reykjavik Iceland
| | - Per K. Hyldmo
- Faculty of Health Sciences University of Stavanger Stavanger Norway
- Department of Research Norwegian Air Ambulance Foundation Oslo Norway
- Trauma Unit Sørlandet Hospital Kristiansand Norway
| | - Kristian D. Friesgaard
- Research Department Prehospital Emergency Medical Service Central Denmark Region Århus Denmark
- Department of Anaesthesiology Regional Hospital of Horsens Horsens Denmark
| | - Poul Kongstad
- Department of Prehospital Care and Disaster Medicine Region of Skåne Lund Sweden
| | - Jouni Kurola
- Centre for Prehospital Emergency Medicine Kuopio University Hospital and University of Eastern Finland Kuopio Finland
| | - Robert Larsen
- Department of Clinical and Experimental Medicine Faculty of Medicine and Health Sciences University of Linköping Linköping Sweden
| | - Marius Rehn
- Faculty of Health Sciences University of Stavanger Stavanger Norway
- Department of Research Norwegian Air Ambulance Foundation Oslo Norway
- Division of Prehospital Services Air Ambulance Department Oslo University Hospital Oslo Norway
| | - Leif Rognås
- Danish Air Ambulance Aarhus Denmark
- Department of Anaesthesiology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Mårten Sandberg
- Division of Prehospital Services Air Ambulance Department Oslo University Hospital Oslo Norway
- Faculty of Medicine University of Oslo Oslo Norway
| | - Gunn E. Vist
- Division of Health Services Norwegian Institute of Public Health Oslo Norway
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Lourens A, Parker R, Hodkinson P. Prehospital acute traumatic pain assessment and management practices in the Western Cape, South Africa: a retrospective review. Int J Emerg Med 2020; 13:21. [PMID: 32370807 PMCID: PMC7201999 DOI: 10.1186/s12245-020-00278-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 04/07/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Trauma is a common aetiology of acute pain in the emergency setting, and traumatic injuries have been recognised as a global public health crisis leading to numerous deaths and disabilities. This study aimed to identify the prevalence of acute pain among high acuity trauma patients presenting to a public sector emergency medical service and to describe prehospital acute traumatic pain assessment and management practices amongst emergency care providers in the Western Cape Province, South Africa. METHODS A retrospective review of electronic patient care reports of trauma patients treated by the South African Western Cape Emergency Medical Services between January 1 and December 31, 2017 was conducted. Stratified random sampling was utilised to select 2401 trauma patients out of 24,575 that met the inclusion criteria. RESULTS Of the 2401 patients reviewed, 435 (18.1%) had a pain score recorded, of which 423 (97.2%) were experiencing pain. An additional 8.1% (n = 194) of patients had pain or tenderness mentioned in the working diagnosis but no pain score noted. Eighty-one (18.6%) patients experienced mild pain, 175 (40.2%) moderate pain and 167 (38.2%) severe pain. No association was found between a pain score recorded and age group (≤ 14 versus > 14 years) (p = 0.649) or gender (p = 0.139). Only 7.6% of patients with moderate-to-severe pain and 2.8% of all trauma patients received any form of analgesic medication. No association was found between the administration of analgesia and age group (≤ 14 versus > 14 years) (p = 0.151) or gender (p = 0.054). Patients were more likely to receive analgesia if they had a pain score recorded (p < 0.001), were managed by advanced life support practitioners (p < 0.001) or had severe pain (p = 0.001). CONCLUSION Acute trauma pain assessment and management practices in this prehospital cohort are less well established than reported elsewhere and whether this reflects emergency care training, institutional culture, scopes of practice or analgesic resources, requires further research. Emergency medical services need to monitor and promote quality pain care, enhance pain education and ensure that all levels of emergency care providers have access to analgesic medication approved for prehospital use. Clear and rational guidelines would enable better pain management by all cadres of providers, for all levels of pain.
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Affiliation(s)
- Andrit Lourens
- Division of Emergency Medicine, University of Cape Town (UCT), Cape Town, South Africa.
| | - Romy Parker
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - Peter Hodkinson
- Division of Emergency Medicine, University of Cape Town (UCT), Cape Town, South Africa
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Lourens A, Hodkinson P, Parker R. Acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa: a knowledge, attitudes and practices survey. BMC Emerg Med 2020; 20:31. [PMID: 32345230 PMCID: PMC7187518 DOI: 10.1186/s12873-020-00315-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 03/09/2020] [Indexed: 12/24/2022] Open
Abstract
Background Acute pain is frequently encountered in the prehospital setting, and therefore, a fundamental aspect of quality emergency care. Research has shown a positive association between healthcare providers’ knowledge of, and attitudes towards pain and pain management practices. This study aimed to describe the knowledge, attitudes, and practices of emergency care providers regarding acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa. The specific objectives were to, identify gaps in pain knowledge; assess attitudes regarding pain assessment and management; describe pain assessment and management behaviours and practices; and identify barriers to and enablers of pain care. Methods A web-based descriptive cross-sectional survey was conducted among emergency care providers of all qualifications, using a face-validated Knowledge, Attitudes and Practices of Pain survey. Results Responses of 100 participants were included in the analysis. The survey response rate could not be calculated. The mean age of respondents was 34.74 (SD 8.13) years and the mean years’ experience 10.02 (SD 6.47). Most respondents were male (69%), employed in the public/government sector (93%) as operational practitioners (85%) with 54% of respondents having attended medical education on pain care in the last 2 years. The mean percentage for knowledge and attitudes regarding pain among emergency care providers was 58.01% (SD 15.66) with gaps identified in various aspects of pain and pain care. Practitioners with higher qualifications, more years’ experience and those who did not attend medical education on pain, achieved higher scores. Alcohol and drug use by patients were the most selected barrier to pain care while the availability of higher qualified practitioners was the most selected enabler. When asked to record pain scores, practitioners were less inclined to assign scores which were self-reported by the patients in the case scenarios. The participant dropout rate was 35%. Conclusion Our results suggest that there is suboptimal knowledge and attitudes regarding pain among emergency care providers in the Western Cape, South Africa. Gaps in pain knowledge, attitudes and practices were identified. Some barriers and enablers of pain care in the South African prehospital setting were identified but further research is indicated.
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Affiliation(s)
- Andrit Lourens
- Division of Emergency Medicine, University of Cape Town (UCT), Cape Town, South Africa.
| | - Peter Hodkinson
- Division of Emergency Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - Romy Parker
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town (UCT), Cape Town, South Africa
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Häske D, Böttiger BW, Bouillon B, Fischer M, Gaier G, Gliwitzky B, Helm M, Hilbert-Carius P, Hossfeld B, Schempf B, Wafaisade A, Bernhard M. Analgesie bei Traumapatienten in der Notfallmedizin. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-00629-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Acute Pain in the African Prehospital Setting: A Scoping Review. Pain Res Manag 2019; 2019:2304507. [PMID: 31149317 PMCID: PMC6501243 DOI: 10.1155/2019/2304507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/02/2019] [Indexed: 01/21/2023]
Abstract
Background Acute pain is a common reason for seeking prehospital emergency care. Regrettably, acute pain is often underestimated and poorly managed in this setting. The scoping review was conducted to gain insight into existing research on the topic and to make recommendations for future work. Objectives To identify all available evidence related to acute pain assessment and management in the African prehospital setting, describe the extent of the evidence, encapsulate findings, and identify research gaps. Methods The scoping review considered primary and secondary research related to acute pain assessment and management of both medical and traumatic origins in all age groups in the African prehospital setting. The search strategy aimed to identify published, unpublished, and ongoing research which met the inclusion criteria. Potentially eligible studies were identified by a comprehensive search of electronic databases, trial registers, dissertation/thesis databases, grey literature databases, and conference proceedings. Screening and data extraction were conducted independently and in duplicate. Results The comprehensive search identified 3823 potential studies, duplicate titles were removed, and 3358 titles/abstracts were screened. Full text of 66 potentially eligible titles was screened, 60 were excluded, and six publications met the inclusion criteria. Despite recommendations for pain assessment during general patient care, most studies reported no/limited pain assessment. In general, pain management was concluded to be insufficient and not conforming to best practice. Conclusions Only six publications addressing prehospital acute pain care in Africa could be identified, possibly indicative of a knowledge gap. Future research is indicated to enable a better understanding of the epidemiology of acute pain and barriers and enablers of acute pain care and to develop evidence-based clinical practice guidelines (CPGs) catering for all EMS systems in Africa. Additionally, educational initiatives should be implemented to improve the quality of acute pain care and to monitor quality through continuous quality improvement (CQI) programs.
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