ABSTRACT
OBJECTIVE: Following recent changes to the German Narcotics Act, this article examines prehospital analgesia by paramedics using piritramide vs. nalbuphineâ¯+ paracetamol. MATERIAL AND METHODS: Prehospital analgesia administered by paramedics from the Fulda (piritramide) and Gütersloh (nalbuphineâ¯+ paracetamol) emergency services was compared regarding pain intensity at the beginning and end of the mission, measured using the numeric rating scale (NRS). Additionally, an analysis of the resulting complications was carried out. RESULTS: In this study 2429 administrations of analgesia were evaluated (nalbuphineâ¯+ paracetamol: 1635, 67.3%, initial NRS: 8.0⯱ 1.4, end of NRS: 3.7⯱ 2.0; piritramide: 794, 32.7%, initial NRS: 8.5⯱ 1.1, end of NRS: 4.5⯱ 1.6). Factors influencing NRS change were initial NRS (regression coefficient, RC: 0.7075, 95% confidence interval, CI: 0.6503-0.7647, pâ¯< 0.001), treatment with nalbuphineâ¯+ paracetamol (RC: 0.6048, 95% CI: 0.4396-0.7700, pâ¯< 0.001). Treatment with nalbuphineâ¯+ paracetamol (nâ¯= 796 (48.7%)) compared to piritramide (nâ¯= 190 (23.9%)) increased the odds of achieving NRSâ¯< 4 (odds ratio, OR: 2.712, 95% CI: 2.227-3.303, pâ¯< 0.001). Complications occurred in nâ¯= 44 (5.5%) with piritramide and in nâ¯= 35 (2.1%) with nalbuphineâ¯+ paracetamol. Risk factors for complications were analgesia with piritramide (OR: 2.699, 95% CI: 1.693-4.301, pâ¯< 0.001), female sex (OR: 2.372, 95% CI: 1.396-4.029, pâ¯= 0.0014), and age (OR: 1.013, 95% CI: 1.002-1.025, pâ¯= 0.0232). CONCLUSION: Compared with piritramide, prehospital analgesia with nalbuphineâ¯+ paracetamol has favorable effects in terms of analgesic efficacy and complication rates and should therefore be considered in future recommendations for paramedics.
Subject(s)
Acetaminophen , Emergency Medical Services , Nalbuphine , Pirinitramide , Nalbuphine/administration & dosage , Nalbuphine/therapeutic use , Nalbuphine/adverse effects , Humans , Acetaminophen/therapeutic use , Acetaminophen/administration & dosage , Acetaminophen/adverse effects , Female , Male , Middle Aged , Adult , Pirinitramide/administration & dosage , Pirinitramide/therapeutic use , Aged , Allied Health Personnel , Pain Measurement , Analgesics, Opioid/administration & dosage , Analgesics, Opioid/adverse effects , Analgesics, Opioid/therapeutic use , Analgesia/methods , Analgesics, Non-Narcotic/administration & dosage , Analgesics, Non-Narcotic/therapeutic use , Analgesics, Non-Narcotic/adverse effects , Young Adult , Adolescent , ParamedicsABSTRACT
BACKGROUND: Despite the development of various analgesic concepts, prehospital oligoanalgesia remains very common. The present work examines prehospital analgesia by paramedics using morphine vs. nalbuphine + paracetamol. METHODS: Patients with out-of-hospital-analgesia performed by paramedics from the emergency medical services of the districts of Fulda (morphine) and Gütersloh (nalbuphine + paracetamol) were evaluated with regards to pain intensity at the beginning and the end of prehospital treatment using the Numeric-Rating-Scale for pain (NRS), sex, age, and complications. The primary endpoint was achievement of adequate analgesia, defined as NRS < 4 at hospital handover, depending on the analgesics administered (nalbuphine + paracetamol vs. morphine). Pain intensity before and after receiving analgesia using the NRS, sex, age and complications were also monitored. RESULTS: A total of 1,808 patients who received out-of-hospital-analgesia were evaluated (nalbuphine + paracetamol: 1,635 (90.4%), NRS-initial: 8.0 ± 1.4, NRS-at-handover: 3.7 ± 2.0; morphine: 173(9.6%), NRS-initial: 8.5 ± 1.1, NRS-at-handover: 5.1 ± 2.0). Factors influencing the difference in NRS were: initial pain intensity on the NRS (regression coefficient (RK): 0.7276, 95%CI: 0.6602-0.7950, p < 0.001), therapy with morphine vs. nalbuphine + paracetamol (RK: -1.2594, 95%CI: -1.5770 - -0.9418, p < 0.001) and traumatic vs. non-traumatic causes of pain (RK: -0.2952, 95%CI: -0.4879 - -0.1024, p = 0.002). Therapy with morphine (n = 34 (19.6%)) compared to nalbuphine + paracetamol (n = 796 (48.7%)) (odds ratio (OR): 0.274, 95%CI: 0.185-0.405, p < 0.001) and the initial NRS score (OR:0.827, 95%CI: 0.771-0.887, p < 0.001) reduced the odds of having an NRS < 4 at hospital handover. Complications occurred with morphine in n = 10 (5.8%) and with nalbuphine + paracetamol in n = 35 (2.1%) cases. Risk factors for complications were analgesia with morphine (OR: 2.690, 95%CI: 1.287-5.621, p = 0.008), female sex (OR: 2.024, 95%CI: 1.040-3.937, p = 0.0379), as well as age (OR: 1.018, 95%CI: 1.003-1.034, p = 0.02). CONCLUSIONS: Compared to morphine, prehospital analgesia with nalbuphine + paracetamol yields favourable effects in terms of analgesic effectiveness and a lower rate of complications and should therefore be considered in future recommendations for prehospital analgesia.
Subject(s)
Acetaminophen , Analgesics, Opioid , Morphine , Nalbuphine , Pain Measurement , Adult , Aged , Female , Humans , Male , Middle Aged , Acetaminophen/therapeutic use , Acetaminophen/administration & dosage , Analgesics, Non-Narcotic/administration & dosage , Analgesics, Non-Narcotic/therapeutic use , Analgesics, Opioid/administration & dosage , Analgesics, Opioid/therapeutic use , Emergency Medical Services/methods , Morphine/administration & dosage , Morphine/therapeutic use , Nalbuphine/administration & dosage , Nalbuphine/therapeutic use , Pain Management/methods , ParamedicsABSTRACT
BACKGROUND: Out-of-hospital analgosedation in trauma patients is challenging for emergency physicians due to associated complications. We compared peripheral nerve block (PNB) with analgosedation (AS) as an analgetic approach for patients with isolated extremity injury, assuming that prehospital required medical interventions (e.g. reduction, splinting of dislocation injury) using PNB are less painful and more feasible compared to AS. METHODS: Thirty patients (aged 18 or older) were randomized to receive either ultrasound-guided PNB (10 mL prilocaine 1%, 10 mL ropivacaine 0.2%) or analgosedation (midazolam combined with s-ketamine or with fentanyl). Reduction-feasibility was classified (easy, intermediate, impossible) and pain scores were assessed using numeric rating scales (NRS 0-10). RESULTS: Eighteen patients were included in the PNB-group and twelve in the AS-group; 15 and 9 patients, respectively, suffered dislocation injury. In the PNB-group, reduction was more feasible (easy: 80.0%, impossible: 20.0%) compared to the AS-group (easy: 22.2%, intermediate: 22.2%, impossible: 55.6%; p = 0.01). During medical interventions, 5.6% [1/18] of the PNB-patients and 58.3% [7/12] of the AS-patients experienced pain (p<0.01). Recorded pain scores were significantly lower in the PNB-group during prehospital medical intervention (median[IQR] NRS PNB: 0[0-0]) compared to the AS-group (6[0-8]; p<0.001) as well as on first day post presentation (NRS PNB: 1[0-5], AS: 5[5-7]; p = 0.050). All patients of the PNB-group would recommend their analgesic technique (AS: 50.0%, p<0.01). CONCLUSIONS: Prehospital ultrasound-guided PNB is rapidly performed in extremity injuries with high success. Compared to the commonly used AS in trauma patients, PNB significantly reduces pain intensity and severity.
Subject(s)
Analgesia/methods , Anesthetics, Local/administration & dosage , Extremities/injuries , Joint Dislocations/complications , Nerve Block/methods , Pain, Postoperative/prevention & control , Ultrasonography/methods , Extremities/diagnostic imaging , Feasibility Studies , Female , Humans , Joint Dislocations/diagnostic imaging , Joint Dislocations/physiopathology , Male , Middle Aged , Pain Management , Pain, Postoperative/etiology , Prospective StudiesABSTRACT
PURPOSE: Procalcitonin (PCT) is accepted to be a relevant prognostic marker for the development of clinical complications in multiple trauma patients. Therefore, a prospective cohort study was conducted to investigate whether polymorphisms in the calcitonin (CALCA) gene are associated with PCT levels and posttraumatic complications. METHODS: During a 14day observation period, blood samples were drawn once daily for systemic PCT concentrations in multiple trauma patients (Injury Severity Score >16). For analysis of allele frequencies, genotype distribution and PCT concentrations polytraumatized patients were separated, according to the development of SIRS, sepsis, septic shock, ARDS, MODS and mortality. Furthermore, association between CALCA polymorphisms and PCT plasma concentrations was assessed. RESULTS: One hundred thirty seven patients with a mean ISS of 29.2+/-12.1 were included. When trauma patients were grouped according to different posttraumatic complications no association with CALCA SNPs was observed. Additionally, no association was found between CALCA polymorphisms and systemic PCT levels. CONCLUSION: CALCA polymorphisms are unlikely to influence clinical outcome in polytraumatized patients. Effects of microbial and inflammatory mediators, as well as other risk factors (gender, age, etc.) seem to have a more significant influence on the transcriptional regulation of CALCA and on PCT plasma concentrations than CALCA polymorphisms.