[Analgesia for trauma patients in emergency medicine]. / Analgesie bei Traumapatienten in der Notfallmedizin.

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.

[Prehospital analgesia by emergency physicians and paramedics : Comparison of effectiveness]. / Prähospitale Analgosedierung durch Notärzte und Rettungsassistenten : Vergleich der Effektivität.

BACKGROUND: In some German emergency medical service districts, analgesia is performed by paramedics without support of emergency physicians on scene. With regard to safety and effectiveness, paramedics should not be overshadowed by emergency physicians. OBJECTIVES: Is prehospital analgesia performed by paramedics under medical supervision or emergency physicians comparable regarding processes and effectiveness in the case of isolated limb injury? MATERIAL AND METHODS: As a retrospective analysis of patients with isolated limb injury, analgesia performed by paramedics and by emergency physicians was analyzed. In addition to pain reduction, prescribed monitoring, and further airway maneuvers, vital parameters (Glasgow coma scale, systolic blood pressure, heartrate and respiratory rate, oxygen saturation) were recorded at the beginning and end of prehospital treatment. RESULTS: Pain was reduced from NRS 8 ± 1 to NRS 2 ± 1 in the paramedic group, and from NRS 8 ± 2 to NRS 2 ± 2 in the physician group, so the mean pain reduction was 6 ± 2 in the paramedic-group and 5 ± 2 in the physician group (p < 0.001). Adequate analgesia was found in 96.9% in the physician group and 91.7% in the paramedic group (p = 0.113). ECG monitoring and oxygen administration according to SOP was significantly more frequent in the paramedic group than in the physician group (p < 0.001). Respiratory frequency was significantly more frequent in the physician group than in the paramedic group (p < 0.001). CONCLUSIONS: The study shows, with a given indication, that German paramedics can independently perform safe and successful analgesia under medical supervision.

[Prehospital analgesia performed by paramedics: quality in processes and effects under medical supervision]. / Prähospitale Analgosedierung durch Rettungsassistenten : Effektivität und Prozessqualität unter ärztlicher Supervision.

BACKGROUND: In the context of the new education program for German paramedics, a discussion has been fueled regarding the emergency care competencies of paramedics. In 1999 a system for training and qualification of paramedics was established in the emergency medical service (EMS) area of Reutlingen (Germany), including an algorithm for analgesia using ketamine and midazolam. Under defined circumstances analgesia may be administered to patients in the absence of a physician. AIM: The objectives of the study were to evaluate the effectiveness of pain reduction measured by a recognized assessment scale and the safety of analgesia with ketamine and midazolam administered by paramedics. This study specifically focused on the medical results and associated processes and not on the legal aspects. MATERIALS AND METHODS: In a retrospective analysis analgesia performed by paramedics who had undergone standardized training with annual controls and under medical supervision was investigated with regard to administration processes and efficacy. Analysis endpoints included vital signs at baseline and on transfer to the emergency department, pain score as defined by a numeric rating scale (NRS 0-10), the amount of ketamine administered and the occurrence of side effects (e.g. respiratory and circulatory disorders, nausea, qualitative and quantitative disturbance of consciousness). RESULTS: A total of 528 instances of analgesia performed by paramedics were registered. The average patient age was 48 ± 23 years (range 5-95 years). Trauma to the extremities was the most common indication for the administration of analgesia with 48 % and 38 % attributable to the upper and lower extremities, respectively. Serious complications were not observed. Administration of analgesia resulted in a highly significant reduction in pain scores (NRS p<0.0001). Mean initial pain score was 8 with an interquartile range (IQR) of 7-8 and a 95% confidence interval (95% CI) of 7.5-7.9 which was decreased to 3 (IQR 2-3, 95% CI 2.2-2.7) on transfer to the emergency department. The number of patients with a pain score of NRS ≤4 in the emergency department was 96 % (n=506). All other vital signs were essentially unchanged and the rate of side effects was low (2.8 %). Potentially life-threatening complications were not reported. The mean midazolam dosage administered was 1 ± 0.4 mg and the mean dosage of ketamine was 27 ± 12 mg. The investigation was limited by restricted documentation and patients who were not treated with analgesics were not included in the study. CONCLUSION: After appropriate training and regular control analgesia administered by paramedics in the present system was safely and effectively applied.