Evaluation of Safety and Efficacy of Prehospital Paramedic Administration of Sub-Dissociative Dose of Ketamine in the Treatment of Trauma-Related Pain in Adult Civilian Population

Analgesic Therapy with the Opioids Fentanyl and Morphine by Ambulance Personnel in Rural Areas: An Observational Study Over 7 Years

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.

Application of analgesics in emergency services in Germany: a survey of the medical directors

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.

Comparing the Effects of Low-Dose Ketamine, Fentanyl, and Morphine on Hemorrhagic Tolerance and Analgesia in Humans

Hemorrhage is a leading cause of preventable battlefield and civilian trauma deaths. Ketamine, fentanyl, and morphine are recommended analgesics for use in the prehospital (i.e., field) setting to reduce pain. However, it is unknown whether any of these analgesics reduce hemorrhagic tolerance in humans. We tested the hypothesis that fentanyl (75 µg) and morphine (5 mg), but not ketamine (20 mg), would reduce tolerance to simulated hemorrhage in conscious humans. Each of the three analgesics was evaluated independently among different cohorts of healthy adults in a randomized, crossover (within drug/placebo comparison), placebo-controlled fashion using doses derived from the Tactical Combat Casualty Care Guidelines for Medical Personnel. One minute after an intravenous infusion of the analgesic or placebo (saline), we employed a pre-syncopal limited progressive lower-body negative pressure (LBNP) protocol to determine hemorrhagic tolerance. Hemorrhagic tolerance was quantified as a cumulative stress index (CSI), which is the sum of products of the LBNP and the duration (e.g., [40 mmHg x 3 min] + [50 mmHg x 3 min] …). Compared with ketamine (p = 0.002 post hoc result) and fentanyl (p = 0.02 post hoc result), morphine reduced the CSI (ketamine (n = 30): 99 [73-139], fentanyl (n = 28): 95 [68-130], morphine (n = 30): 62 [35-85]; values expressed as a % of the respective placebo trial's CSI; median [IQR]; Kruskal-Wallis test p = 0.002). Morphine-induced reductions in tolerance to central hypovolemia were not well explained by a prediction model including biological sex, body mass, and age (R2=0.05, p = 0.74). These experimental data demonstrate that morphine reduces tolerance to simulated hemorrhage while fentanyl and ketamine do not affect tolerance. Thus, these laboratory-based data, captured via simulated hemorrhage, suggest that morphine should not be used for a hemorrhaging individual in the prehospital setting.