Prehospital Analgesia: Systematic Review of Evidence

Abstract

The purpose of this systematic review is to investigate current evidence for analgesic use in the prehospital environment using expert military and civilian opinion to determine the important clinical questions. There was a high degree of agreement that pain should be no worse than mild, that pain relief be rapid (within 10 minutes), that patients should respond to verbal stimuli and not require ventilatory support, and that major adverse events should be avoided. Twenty-one studies provided information about 6,212 patients; the majority reported most of the outcomes of interest. With opioids 60-70% of patients still had pain levels above 30/100 mm on a Visual Analogue Scale after 10 minutes, falling to about 30% by 30-40 minutes. Fascia iliaca blocks demonstrated some efficacy for femoral fractures. No patient on opioids required ventilatory support; two required naloxone; sedation was rare. Cardiovascular instability was uncommon. Main adverse events were dizziness or giddiness, and pruritus with opioids. There was little evidence regarding the prehospital use of ketamine. group.bmj.com on July 28, 2015 -Published by http://jramc.bmj.com/ Downloaded from Pre-hospital analgesia J R Army Med Corps 156 (4 Suppl 1): S295-300 CL Park, DE Roberts, DJ Aldington et al Pre-hospital analgesia J R Army Med Corps 156 (4 Suppl 1): S295-300 CL Park, DE Roberts, DJ Aldington et al

Is intramuscular morphine satisfying frontline medical personnels’ requirement for battlefield analgesia in Helmand Province, Afghanistan? A questionnaire study

“…3,5,6,18,19 In our study, a higher proportion of CMTs had treated casualties on the battlefield compared to MOs. This is likely to be due to the hub-and-spoke distribution of medical staff, with CMTs providing forward medical capability and MOs providing centralised clinical support.…”

“…Despite IM morphine being distributed to every deployed British soldier, a systematic review of 21 studies of pre-hospital analgesics in 6212 patients did not include any studies of this agent, 3 and its use by the British military appears historical. The earliest documentation of its use first appeared during the Crimean War.…”

Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study

“…On average, physicians had 5.7 yr of postgraduate training (Table 1). The median number of missions per physician was [13][14][15][16][17][18][19][20], with a range of 1-54 missions (Fig. 2).…”

Pain priorities in pre-hospital care

“…Their onset is relatively rapid, however 60e70% of patients report moderate or severe pain 10 minutes following administration. 1 Intravenous morphine has long been the gold standard for management of severe pain. It can be given intramuscularly in the absence of intravenous access, and 10 mg autojets are issued to British Military personnel on active duty for the purpose of selfadministration.…”