An Evidence-based Guideline for prehospital analgesia in trauma.

BACKGROUND: The management of acute traumatic pain is a crucial component of prehospital care and yet the assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based regional protocols. OBJECTIVE: To develop an evidence-based guideline (EBG) for the clinical management of acute traumatic pain in adults and children by advanced life support (ALS) providers in the prehospital setting. Methods. We recruited a multi-stakeholder panel with expertise in acute pain management, guideline development, health informatics, and emergency medical services (EMS) outcomes research. Representatives of the National Highway Traffic Safety Administration (sponsoring agency) and a major children's research center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide the process of question formulation, evidence retrieval, appraisal/synthesis, and formulation of recommendations. The process also adhered to the National Prehospital Evidence-Based Guideline (EBG) model process approved by the Federal Interagency Council for EMS and the National EMS Advisory Council. RESULTS: Four strong and three weak recommendations emerged from the process; two of the strong recommendations were linked to high- and moderate-quality evidence, respectively. The panel recommended that all patients be considered candidates for analgesia, regardless of transport interval, and that opioid medications should be considered for patients in moderate to severe pain. The panel also recommended that all patients should be reassessed at frequent intervals using a standardized pain scale and that patients should be re-dosed if pain persists. The panel suggested the use of specific age-appropriate pain scales. CONCLUSION: GRADE methodology was used to develop an evidence-based guideline for prehospital analgesia in trauma. The panel issued four strong recommendations regarding patient assessment and narcotic medication dosing. Future research should define optimal approaches for implementation of the guideline as well as the impact of the protocol on safety and effectiveness metrics.

The association between emergency medical services staffing patterns and out-of-hospital cardiac arrest survival.

OBJECTIVE: To determine whether the number of advanced life support-trained personnel at the scene of an out-of-hospital cardiac arrest (OHCA) was associated with return of spontaneous circulation (ROSC) or survival to hospital discharge. METHODS: A retrospective database review using Utstein-style reporting definitions was conducted in Milwaukee County. All adult (>or= 18 years of age) OHCA cases of presumed cardiac etiology from January 1993 through December 2005 were eligible for inclusion in the study. Cardiac arrests resulting from a drug overdose, suicide, drowning, hypoxia, exsanguination, stroke, or trauma were excluded from the study. Also excluded were cases in which no crew configuration or responding unit was available, cases in which no resuscitation effort was attempted, and cases in which no time data were available. Return of spontaneous circulation and survival to hospital discharge for OHCA patients treated by a crew with two paramedics were compared to those patients treated by crews with three or more paramedics. Multivariable logistic regression was used for the analysis and the results are reported as odds ratios (ORs). RESULTS: During the study period, there were 10,298 OHCAs of cardiac etiology. Of those, 10,057 (98%) cases had sufficient data to be included in the analysis. There were 4,229 patients treated by two paramedics (9% survived to discharge), 4,459 patients treated by three paramedics (9% survived to discharge), and 1,369 patients treated by four or more paramedics (8% survived to discharge). In the multivariable analysis, when referenced against crews with two paramedics and controlled for factors that have a known correlation with cardiac arrest survival, patients treated by crews with three paramedics (0.83, 95% confidence interval [CI] 0.70 to 0.97, p = 0.02) and crews with four or more paramedics (0.66, 95% CI 0.52 to 0.83, p < 0.01) were associated with reduced survival to hospital discharge. Return of spontaneous circulation was not influenced by the number of paramedics present. CONCLUSIONS: The presence of three or more paramedics at the scene of OHCA was not associated with improved survival to hospital discharge when compared to crews with two paramedics. Additional research is needed to determine the potential cause of this finding.