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Smith J, Soo D, Celenza A. Triage-initiated intranasal fentanyl for hip fractures in an Emergency Department - Results from introduction of an analgesic guideline. Int Emerg Nurs 2024; 74:101445. [PMID: 38579496 DOI: 10.1016/j.ienj.2024.101445] [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: 08/30/2023] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Pain relief is a priority for patients with hip fractures who present to Emergency Departments (EDs). Intranasal fentanyl (INF) is an ideal option for nurse initiated analgesia as it does not require intravenous access and can expedite care prior to examination by a physician. LOCAL PROBLEM Pain relief in patients with hip fractures is delayed during episodes of ED crowding. METHODS A retrospective medical record review was conducted following introduction of an INF guideline in an adult ED in 2018. Patients were included over a 4-month period during which the guideline was introduced. Historical and concurrent control groups receiving usual care were compared to patients receiving INF. INTERVENTIONS This quality improvement initiative investigated whether an INF analgesia at triage guideline would decrease time to analgesic administration in adults with hip fracture in ED. RESULTS This study included 112 patients diagnosed with fractured hips of which 16 patients received INF. Background characteristics were similar between groups. Mean time to analgesic administration (53 v 110 minutes), time to x-ray (46 v 75 minutes), and ED length of stay (234 v 298 minutes) were significantly decreased in the intervention group. Inadequate documentation was a limiting factor in determining improved efficacy of analgesia. CONCLUSION Use of triage-initiated INF significantly decreased time to analgesic administration, time to imaging and overall length of stay in ED.
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Affiliation(s)
- Jennifer Smith
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia
| | - Danny Soo
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia
| | - Antonio Celenza
- Emergency Department, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia; Division of Emergency Medicine, University of Western Australia, Stirling Highway, Nedlands, Western Australia, Australia.
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de Grunt MN, de Jong B, Hollmann MW, Ridderikhof ML, Weenink RP. Parenteral, Non-Intravenous Analgesia in Acute Traumatic Pain-A Narrative Review Based on a Systematic Literature Search. J Clin Med 2024; 13:2560. [PMID: 38731088 PMCID: PMC11084350 DOI: 10.3390/jcm13092560] [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: 03/19/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Traumatic pain is frequently encountered in emergency care and requires immediate analgesia. Unfortunately, most trauma patients report sustained pain upon arrival at and discharge from the Emergency Department. Obtaining intravenous access to administer analgesics can be time-consuming, leading to treatment delay. This review provides an overview of analgesics with both fast onset and parenteral, non-intravenous routes of administration, and also indicates areas where more research is required.
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Affiliation(s)
- Midas N. de Grunt
- Department of Anaesthesiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (M.N.d.G.); (B.d.J.); (M.W.H.)
| | - Bianca de Jong
- Department of Anaesthesiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (M.N.d.G.); (B.d.J.); (M.W.H.)
| | - Markus W. Hollmann
- Department of Anaesthesiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (M.N.d.G.); (B.d.J.); (M.W.H.)
| | - Milan L. Ridderikhof
- Department of Emergency Medicine, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands;
| | - Robert P. Weenink
- Department of Anaesthesiology, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands; (M.N.d.G.); (B.d.J.); (M.W.H.)
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Heydari F, Azizkhani R, Majidinejad S, Zamani M, Norouzian A. A comparative study of intranasal desmopressin and intranasal ketamine for pain management in renal colic patients: a randomized double-blind clinical trial. Clin Exp Emerg Med 2024; 11:51-58. [PMID: 37439138 PMCID: PMC11009705 DOI: 10.15441/ceem.23.059] [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: 05/10/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVE Urolithiasis is one of the most common urological diseases worldwide, usually presenting as renal colic that leads to severe pain that requires analgesic treatment. This study aimed to compare the efficacy of ketamine and desmopressin in the pain management of renal colic patients. METHODS This double-blind, randomized clinical trial was conducted on renal colic patients referred to the emergency department from June 2021 to July 2022. Patients were randomly assigned to three groups. In the desmopressin group, patients were treated with intranasal desmopressin and intravenous ketorolac. The ketamine group was treated with intranasal ketamine and ketorolac. The control group received ketorolac and an intranasal placebo. Vital signs were evaluated at baseline and 60 minutes; and pain scores were assessed at baseline, 10, 30, and 60 minutes after treatment. RESULTS Enrollment included 135 patients, the mean (standard deviation) age was 44.1±11.4 years, and 82 (60.7%) were men. The mean visual analog scale scores were significantly lower at 10, 30, and 60 minutes in the ketamine group (5.6±1.2, 3.0±1.1, and 0.9±0.9, respectively) compared to the control (8.2±1.1, 5.1±2.0, and 2.3±2.6, respectively) and desmopressin (6.7±1.8, 4.2±2.2, and 1.3±1.4, respectively) groups (P<0.05). Although patients in the desmopressin group had lower mean pain scores than the control group at 10, 30, and 60 minutes, this difference was only significant at 10 minutes after the intervention (P<0.05). No significant differences in vital signs were found at 60 minutes after treatment. CONCLUSION Ketamine showed more favorable analgesic effects in renal colic patients than desmopressin, although desmopressin showed efficacy in the first minutes posttreatment.
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Affiliation(s)
- Farhad Heydari
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Azizkhani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Majidinejad
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Zamani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Aref Norouzian
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Nasr Isfahani M, Etesami H, Ahmadi O, Masoumi B. Comparing the efficacy of intravenous morphine versus ibuprofen or the combination of ibuprofen and acetaminophen in patients with closed limb fractures: a randomized clinical trial. BMC Emerg Med 2024; 24:15. [PMID: 38273252 PMCID: PMC10809472 DOI: 10.1186/s12873-024-00933-y] [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: 08/31/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION This study aims to investigate the effectiveness of intravenous ibuprofen or intravenous ibuprofen plus acetaminophen compared to intravenous morphine in patients with closed extremity fractures. METHODS A triple-blinded randomized clinical trial was conducted at a tertiary trauma center in Iran. Adult patients between 15 and 60 years old with closed, isolated limb fractures and a pain intensity of at least 6/10 on the visual analog scale (VAS) were eligible. Patients with specific conditions or contraindications were not included. Participants were randomly assigned to receive intravenous ibuprofen, intravenous ibuprofen plus acetaminophen, or intravenous morphine. Pain scores were assessed using the visual analog scale at baseline and 5, 15, 30, and 60 min after drug administration. The primary outcome measure was the pain score reduction after one hour. RESULTS Out of 388 trauma patients screened, 158 were included in the analysis. There were no significant differences in age or sex distribution among the three groups. The pain scores decreased significantly in all groups after 5 min, with the morphine group showing the lowest pain score at 15 min. The maximum effect of ibuprofen was observed after 30 min, while the ibuprofen-acetaminophen combination maintained its effect after 60 min. One hour after injection, pain score reduction in the ibuprofen-acetaminophen group was significantly more than in the other two groups, and pain score reduction in the ibuprofen group was significantly more than in the morphine group. CONCLUSION The study findings suggest that ibuprofen and its combination with acetaminophen have similar or better analgesic effects compared to morphine in patients with closed extremity fractures. Although morphine initially provided the greatest pain relief, its effect diminished over time. In contrast, ibuprofen and the ibuprofen-acetaminophen combination maintained their analgesic effects for a longer duration. The combination therapy demonstrated the most sustained pain reduction. The study highlights the potential of non-opioid analgesics in fracture pain management and emphasizes the importance of initiation of these medications as first line analgesic for patients with fractures. These findings support the growing trend of exploring non-opioid analgesics in pain management. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05630222 (Tue, Nov 29, 2022). The manuscript adheres to CONSORT guidelines.
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Affiliation(s)
- Mehdi Nasr Isfahani
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Trauma Data Registration Center, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Etesami
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Student Research Committee, Vice Chancellery for Research, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Ahmadi
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Babak Masoumi
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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Shetabi H, Peyman A, Piudeh F. Comparing the Effectiveness and Safety of Giving Fentanyl or Ketamine Intranasally during Phacoemulsification Surgery. Galen Med J 2023; 12:1-8. [PMID: 38974131 PMCID: PMC11227644 DOI: 10.31661/gmj.v12i.2921] [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: 01/20/2023] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Phacoemulsification is the main method of cataract surgery in developed countries. Due to the importance of appropriate analgesia and the immobility of the participants throughout the procedure, the study aimed to assess the impact of intranasal ketamine vs. intranasal fentanyl on the quality of sedation and analgesia in phacoemulsification surgery. MATERIALS AND METHODS This double-blinded study was carried out on participants who underwent cataract surgery in Faiz Hospital, Isfahan, Iran. Eighty subjects were randomly assigned to two groups of 40 receiving ketamine at a dosage of 1.5 mg/kg intranasally (Intranasal Ketamine (INK) group) or fentanyl at 1.5 μg/kg nasally (Intranasal Fentanyl (INF) group). The drugs were administered through the nasal passage 15 minutes before the operation. The primary outcomes were a difference in the quality of sedation and pain relief between groups during the procedure and recovery unit. Secondary outcomes were cardiovascular parameters, side effects, the need for sedative rescues, and changes in vital signs. RESULTS During the study, 25 patients (62.5%) in the INK cohort and 19 patients (47.5%) in the INF cohort had no pain. In the INK group, 22 (55%) and in the INF group 20 (50.0%) patients achieved optimal sedation (Ramsay sedation score 4). There was no discernible disparity observed between the two cohorts in terms of the quality of sedation (P=0.071), receipt of rescue dosage of propofol (P=0.601), hemodynamic parameters (P0.05), and side effects during treatment Operation (P=0.542) and in recovery (P=0.104), patient (P=0.098) and surgeon (P=0.120) satisfaction, operative time (P=0.082), and duration of stay in recovery (P=0.110). CONCLUSION Although INK was more effective than INF in reducing pain and achieving optimal sedation in cataract surgery, it was not significantly superior to INF.
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Affiliation(s)
- Hamidreza Shetabi
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center,
Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Peyman
- Department of Ophthalmology, Ophthalmology Research Center, Isfahan University of
Medical Sciences, Isfahan, Iran
| | - Farzan Piudeh
- Student Research Committee, Medical School, Isfahan University of Medical Sciences,
Isfahan, Iran
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Isfahani MN, Naseh K, Golshani K. Mini-dose Bier's block vs systemic analgesia in distal radius fractures: a promising reduction in emergency department throughput time. Pain Manag 2023; 13:433-443. [PMID: 37718930 DOI: 10.2217/pmt-2023-0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Aim: This study compared the effect of the conventional technique of procedural sedation and the mini-dose intravenous regional anesthesia (IVRA). Patients & methods: 45 patients received IVRA, and 47 received iv. ketamine. The pain score, emergency department (ED) length of stay and patients' satisfaction were compared. Results: The study revealed that not only the levels of hemodynamic parameters but also their stability, and the patient's satisfaction in the IVRA group were significantly better. The patients' pain score and ED length of stay were also significantly decreased in those who received IVRA. Conclusion: Mini-dose IVRA technique contributes to better hemodynamic stability, without prominent adverse events, and leads to significant pain control and improved ED throughput time. Clinical Trial Registration: NCT03349216 (ClinicalTrials.gov).
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Affiliation(s)
- Mehdi Nasr Isfahani
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran
- Trauma Data Registration Center, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, 8174673461, Iran
| | - Keivan Naseh
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran
| | - Keihan Golshani
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, 8174675731, Iran
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Serra S, Spampinato MD, Riccardi A, Guarino M, Pavasini R, Fabbri A, De Iaco F. Intranasal Fentanyl for Acute Pain Management in Children, Adults and Elderly Patients in the Prehospital Emergency Service and in the Emergency Department: A Systematic Review. J Clin Med 2023; 12:2609. [PMID: 37048692 PMCID: PMC10095441 DOI: 10.3390/jcm12072609] [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: 02/22/2023] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023] Open
Abstract
This systematic review examined the efficacy and safety of intranasal fentanyl (INF) for acute pain treatment in children, adults, and the elderly in prehospital emergency services (PHES) and emergency departments (ED). ClinicalTrials.gov, LILACS, PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane databases were consulted until 31 December 2022. A total of 23 studies were included: 18 in children (1 PHES, 17 ED), 5 in adults (1 PHES, 4 ED) and 1 in older people (1 PHES subgroup analysis). In children, INF was effective in both settings and as effective as the comparator drugs, with no differences in adverse events (AEs); one randomised controlled trial (RCT) showed that INF was more effective than the comparator drugs. In adults, one study demonstrated the efficacy of INF in the PHES setting, one study demonstrated the efficacy of INF in the ED setting, two RCTs showed INF to be less effective than the comparator drugs and one RCT showed INF to be as effective as the comparator, with no difference in AEs reported. In older people, one study showed effective pain relief and no AEs. In summary, INF appears to be effective and safe in children and adults in PHES and ED. More high-quality studies are needed, especially in PHES and older people.
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Affiliation(s)
- Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47521 Cesena, Italy
| | | | | | - Mario Guarino
- UOC MEU Ospedale CTO- AORN dei Colli Napoli, 80131 Naples, Italy
| | - Rita Pavasini
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Fabio De Iaco
- Struttura Complessa di Medicina di Emergenza Urgenza Ospedale Maria Vittoria, ASL Città di Torino, 10144 Torino, Italy
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Zanza C, Romenskaya T, Zuliani M, Piccolella F, Bottinelli M, Caputo G, Rocca E, Maconi A, Savioli G, Longhitano Y. Acute Traumatic Pain in the Emergency Department. Diseases 2023; 11:diseases11010045. [PMID: 36975594 PMCID: PMC10046963 DOI: 10.3390/diseases11010045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/01/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Trauma is a major cause of mortality throughout the world. Traumatic pain—acute, sudden, or chronic—is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Patients’ perceptions of pain assessment and management have become an important criterion and relevant outcome measure for healthcare institutions. Several studies show that 60–70% of ER patients experience pain, and more than half of them express a feeling of sorrow, which can be moderate or severe, at triage. The few studies that have analyzed how pain is assessed and managed in these departments agree that approximately 70% of patients receive no analgesia or receive it with remarkable delay. Specifically, less than half of the patients receive treatment for pain during admission and 60% of discharged patients have higher intensity pain than at admission. Trauma patients are also the ones who most commonly report low satisfaction with pain management. Associated with this lack of satisfaction, we can describe the poor use of tools for measuring and recording pain, poor communication among caregivers, inadequate training in pain assessment and management, and widespread misconceptions among nurses about the reliability of patients’ estimation of pain. The aim of this article is to review the scientific literature to explore the methodologies of pain management in trauma patients attending the emergency room and analyzing their weaknesses as a starting point to improve the approach to this, unfortunately too often, underestimated issue. A literature search was performed using the major databases to identify relevant studies in indexed scientific journals. The literature showed that the multimodal approach in trauma patients is the best approach to pain management. It is becoming increasingly crucial to manage the patient on multiple fronts. Drugs acting on different pathways can be administered together at lower doses, minimizing risks. Every emergency department must have staff trained in the assessment and immediate management of pain symptoms as this allows the reduction of mortality and morbidity and shortens hospital stays, contributing to early mobilization, reduced hospital costs, and enhanced patient satisfaction and quality of life.
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Affiliation(s)
- Christian Zanza
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
- Correspondence:
| | - Tatsiana Romenskaya
- Department of Physiology and Pharmacology, Sapienza University of Rome, 00185 Rome, Italy
| | - Marta Zuliani
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Fabio Piccolella
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Maria Bottinelli
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Giorgia Caputo
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Eduardo Rocca
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Antonio Maconi
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
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