Comparative Effectiveness of Analgesics To Reduce Acute Pain in the Prehospital Setting

Sobieraj, Diana M; Baker, William L.; Martinez, Brandon K.; Miao, Benjamin; Hernández, Adrian V.; Coleman, Craig I; Cicero, Mark X.; Kamin, Richard

doi:10.23970/ahrqepccer220

Cited by 12 publications

(22 citation statements)

References 26 publications

(56 reference statements)

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“…This manuscript presents the comparisons and outcomes with conclusions and graded strength of evidence (see Strength of Evidence Assessment section). Additional comparisons and outcomes are presented in the full report that is available on the AHRQ website (11).…”

Section: Methodsmentioning

confidence: 99%

“…The prioritized outcomes include changes in pain severity (continuous measures), presence of pain (dichotomous measures), time to analgesic effect, respiratory depression, hypotension, change in mental status, and "any adverse event." Other comparisons and outcomes do not have an accompanying conclusion with SOE and are reported in the full report (11).…”

Section: Strength Of Evidence (Soe) Assessmentmentioning

confidence: 97%

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Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting

Sobieraj

Martinez

Miao³

et al. 2019

Prehospital Emergency Care

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Objectives: The objectives of this study were to assess comparative effectiveness and harms of opioid and nonopioid analgesics for the treatment of moderate to severe acute pain in the prehospital setting. Methods: We searched MEDLINE V R , Embase V R , and Cochrane Central from the earliest date through May 9, 2019. Two investigators screened abstracts, reviewed full-text files, abstracted data, and assessed study level risk of bias. We performed meta-analyses when appropriate. Conclusions were made with consideration of established clinically important differences and we graded each conclusion's strength of evidence (SOE). Results: We included 52 randomized controlled trials and 13 observational studies. Due to the absence or insufficiency of prehospital evidence we based conclusions for initial analgesia on indirect evidence from the emergency department setting. As

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Section: Methodsmentioning

confidence: 99%

Section: Strength Of Evidence (Soe) Assessmentmentioning

confidence: 97%

Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting

Sobieraj

Martinez

Miao³

et al. 2019

Prehospital Emergency Care

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“…20 However, a recent report did not show a significantly greater reduction in the numerical rating scale with ketamine than with morphine. 21 The other reported reason was that participants considered ketamine to have a better safety profile than fentanyl. A better safety profile in favor of ketamine has not been clearly established in the literature.…”

Section: Methods Of Usementioning

confidence: 99%

Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service

Vanolli

Eidenbenz

Suter

et al. 2020

Wilderness & Environmental Medicine

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IntroductiondAlthough ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey. MethodsdThe survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy. ResultsdKetamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg$kg-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1e2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor. ConclusionsdKetamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.

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“…While most providers agree that there are some conditions for which an opiate medication would be considered more appropriate, there is conclusive evidence that there are many conditions common to EMS where non-opiate medications are equally efficacious with regard to both patient safety and satisfaction and therein might be considered more appropriate for use. 15…”

Section: Acknowledgmentsmentioning

confidence: 99%

“…However, there is a considerable body of literature demonstrating non-inferiority in non-opiate medication administration as compared to opiates for many conditions commonly encountered in the prehospital setting including renal colic, long bone fracture, and other minor traumatic limb injuries. [12][13][14][15] While most clinicians are in agreement that prehospital providers should treat pain, there remains equipoise as to how to guide prehospital pain management. Providers must attempt to consolidate information pertaining to patients' self-reported levels of pain, clinical characteristics, and the possible adverse effects of available analgesics, and then make an expeditious decision about which medication to administer.…”

Section: Introductionmentioning

confidence: 99%

Paramedic Pain Management Practice with Introduction of a Non-opiate Treatment Protocol

O’Connor

Dugas

Brady

et al. 2020

WestJEM

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Introduction: There is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol. Methods: This study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017-December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients' clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia. Results: Pain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69-0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96-2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p<0.0001). We surveyed 100 paramedics (mean age 41.98, 84% male). Compositely, 85% of paramedics planned to use nonopiates and 35% reported having done so. Participants planning to use non-opiates were younger and less experienced. Participants indicated that concern about adverse effects, efficacy, and time to effect impacted their practice patterns. Conclusion: The introduction of non-opiate pain medication to state protocols led to reduced opiate administration. Men and trauma patients were more likely to receive opiates. Paramedics reported enthusiasm for non-opiate medications. Beliefs about non-opioid analgesics pertaining to adverse effects, onset time, and efficacy may influence their utilization. [

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Comparative Effectiveness of Analgesics To Reduce Acute Pain in the Prehospital Setting

Cited by 12 publications

References 26 publications

Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting

Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting

Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service

Paramedic Pain Management Practice with Introduction of a Non-opiate Treatment Protocol

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