A Fentanyl-Based Pain Management Protocol Provides Early Analgesia For Adult Trauma Patients

Opioid Administration in the Trauma Bay for Minor Injuries Does Not Improve Disposition

OBJECTIVES

Opioid usage in the trauma bay is a common practice for pain management. We evaluated the administration of opioids to patients with minimal injury to determine disposition and factors for opioid administration.

METHODS

A retrospective study at a single institution was conducted utilizing records of trauma activations with an ISS of 3 or less between 1/1/2022 and 10/29/2022. Patients who are incarcerated, pregnant, or received an opioid prior to arrival were excluded. Categorical variables were analyzed using chi-square tests, and continuous variables were analyzed using t-tests.

RESULTS

557 patients met inclusion criteria. One in five patients were administered an opioid (22%). The majority of patients who received opioids were between the ages of 25 and 44 (OR 1.218 [.693, 2.141]), black (OR 3.077 [2.066, 4.584]), and had Medicaid insurance (OR 1.390 [.883, 2.187]). Patients who received an opioid reported a higher pain level (8 [6, 9] v 5 [2, 8], P = .0001), despite no difference in ISS. No significant difference was found in patient dispositions (P = .1759). When fentanyl was administered, doses greater than 50 mcg were administered to highest activation level trauma patients (40% v 10% P = .0001).

CONCLUSION

Opioid administration for patients with minor injuries does not improve patient disposition. The majority of patients with minor injuries being treated with opioids are young, black, and Medicaid patients. This research suggests consideration for establishing a non-opioid analgesic medication as first-line pain management for patients without evidence of significant injury on initial evaluation.

Emergency nurses perceived barriers to effective pain management at emergency department in Amhara region referral hospitals, Northwest Ethiopia, 2021. Multi-center cross sectional study

Background

Quality of pain management in emergency departments may be affected by nurses' perceived barriers. Poorly managed pain may lead to altered physiological and psychological function which affect patients’ quality of life as well as increase costs to the health care system.

Objective

This study aimed to assess emergency nurse's perceived barriers to pain management and associated factors at emergency departments, 2021.

Methods

A multi-center cross-sectional study was conducted with 153 nurses from eight emergency departments from May1-May 30, 2021 with semi-structured questionnaire. All volunteer nurses were included. Epi-info version 7 and SPSS version 20.0 were used for data entry and analysis respectively. We used descriptive statistics to report results of the study in the form of text and table. Student t-test, one way ANOVA and Post hoc test were applied to assess relationship between socio-demographic characteristics of the participants with perceived barriers.

Result

Of the 20 items, overcrowding 3.24 ± 0.9, nursing workload 3.16 ± 1.03, and lack of pain management guidelines/protocol2.5 ± 1.15 were the highest reported barriers to pain management at an emergency department. In addition, years of work experience as emergency nurses≤1 (p-value = 0.01), BSC level of education (p-value = 0.04), married (p-value = 0.04) and frequency of training ≤ (p-value = 0.02) were significantly associated with nurses perceived barriers on pain management.

Conclusion

and Recommendation: Overcrowding, nurses’ workload, absence of pain management tool, year of experience as emergency nurse ≤1, married, BSC nurses and frequency of training≤1 were the perceived barriers to pain management in the emergency department. The stakeholders in each facility should make an effort to increase the ratio of nurses to emergency patients. Professionals should develop local pain assessment and management protocol. Training should be given regularly and the opportunity of education should be maximized.

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The reported barriers to pain management was high.

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Nursing workload, and lack of pain management guidelines were the factors.

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Moreover, year of experience as emergency nurse ≤1 were among the perceived barriers.

Emergency nurses´ knowledge, attitude and perceived barriers regarding pain Management in Resource-Limited Settings: cross-sectional study

Background

Pain is a common phenomenon among emergency patients which may lead to chronic pain conditions and alteration of physiological function. However, it is widely reported that proper pain assessment and management, which is often accomplished by adequately trained nurses reduce the suffering of patients. Therefore, the aim of this study was to assess the emergency nurses´ knowledge, attitude and perceived barriers regarding pain management.

Methods

A cross-sectional quantitative study design was applied to determine the nurses´ knowledge level, attitude and the perceived barriers related to pain management. Hundred twenty-six nurses from the emergency departments of seven referral hospitals of Eritrea participated in the study. Data were collected in August and September 2017. Both descriptive and inferential statistics were used to summarize and elaborate on the results.

Result

In general, the knowledge level and attitude of the emergency nurses was poor. The participants’ correct mean score was 49.5%. Nurses with Bachelor’s Degree had significantly higher knowledge and attitude level compared to the nurses at the Diploma and Certificate level of professional preparation (95% CI = 7.1–16.7 and 9.4–19.1; p <  0.001) respectively. Similarly, nurses who had previous training regarding pain scored significantly higher knowledge level compared to those without training (95% CI =1.82–8.99; p = 0.003). The highest perceived barriers to adequate pain management in emergency departments were measured to be overcrowding of the emergency department (2.57 ± 1.25), lack of protocols for pain assessment (2.45 ± 1.52), nursing workload (2.44 ± 1.29) and lack of pain assessment tools (2.43 ± 1.43). There was no significant difference in perceived barriers among nurses with different demographic characteristics.

Conclusion

The emergency nurses’ knowledge and attitude regarding pain management were poor. Nurses with higher educational level and nurses with previous training scored significantly higher knowledge level. This indicates the need for nursing schools and the ministry of health to work together to educate nurses to a higher level of preparation for pain assessment and management.

Incidence of chronic pain 6 y after major trauma

BACKGROUND

Life saving measures is the main focus in the initial treatment of major trauma. In surviving patients, chronic pain may be a serious problem, but the long term incidence and potential risk factors are not very well studied.

METHODS

All adult trauma patients included in the institutional trauma registry in 2007 were assessed for eligibility. Among exclusion criteria were: Injury Severity Score < 9, endotracheal intubation before or during admission, spinal cord lesion, known chronic drug or substance abuse, major surgery within 3 h after admission. A patient questionnaire was sent out 6 y after injury focusing on frequency and intensity of pain. A subgroup analysis was done in patients with thoracic injuries, comparing patients with epidural analgesia (EDA) and patients without.

RESULTS

Sixty-eight patients were included in the study. Sixty-nine percent reported pain 6 y after injury and 24% had severe pain. The severity of the injury was a risk factor for development of chronic pain, whereas pain during initial hospital stay was not. In patients with thoracic injuries there was no correlation between initial treatment with EDA and decreased incidence of chronic pain, however patient numbers were small. Opioids were the main analgesics used initially; no patients received non-steroidal anti-inflammatory drugs or peripheral nerve blocks during the first 24 h.

CONCLUSION

Two thirds of the trauma patients had chronic pain 6 y after injury and one out of four had severe pain. The initial pain treatment was focused on opioids.

The effect of pain management in reducing limb and spine radiography in stable traumatic patients admitted to the emergency department

Introduction

Musculoskeletal pain caused by trauma is one of the common complaints of patients referred to the emergency department. Due to the lack of a proper pain control protocol, doctors and nurses do not pay attention to pain, and physicians may tend to request too many radiographs, many of which will be unnecessary. We aimed to study the effect of pain management by fentanyl in reducing the number of radiographs, reducing hospital costs and increasing satisfaction in the patients on patients with isolated trauma in limbs and spine causing musculoskeletal pain.

Patients and methods

A cohort of patients who were referred to the fast-track emergency department with isolated trauma of the upper and lower limbs or spine and triage levels 3, 4 and 5, were visited twice by an emergency medicine resident – before and after application of a pain management protocol using intravenous fentanyl as the principle analgesic. The primary outcome measure was the reduction in the number of radiographs requested; secondary outcomes included alterations in pain levels and patient satisfaction.

Results

A total of 158 patients were included in the study. The median age was 27.5 years, three quarters were male and 20.88% had a positive history of opium addiction. The number and costs of diagnostic radiography significantly decreased after the administration of fentanyl (P < 0.0001), as did pain levels measured on visual analogue scale with a consequent increase in patient satisfaction. There were only six complications resulting from fentanyl administration which were mild and transient. Follow-up after 24–72 h, revealed no missed fractures.

Conclusions

The administration of fentanyl as a strong analgesic as part of an emergency department pain management protocol for trauma patients can be performed with limited minor complications; it can reduce the number of unnecessary X-rays performed, exposure to ionizing radiation and hospital costs as well as improving patient satisfaction without missing fractures.

Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury

BACKGROUND

Rapid and effective pain relief in acute traumatic limb injuries (ATLI) is one of the most important roles of emergency physicians. In these situations, opioid addiction is an important concern because of the dependency on opioids. The study aims to compare the effectiveness of intravenous (IV) fentanyl versus morphine in reducing pain in patients with opioid addiction who suffered from ATLI.

METHODS

In this double-blind randomized clinical trial, 307 patients with ATLI, who presented to the emergency department (ED) from February 2016 to April 2016, were randomly divided into two groups. One group (152 patients) received 0.1 mg/kg IV morphine. The other group (155 patients) received 1 mcg/kg IV fentanyl. Patients' demographic data, pain score at specific intervals, vital signs, side effects, satisfaction and the need for rescue analgesia were recorded.

RESULTS

Eight patients in the morphine group and five patients in the fentanyl group were excluded. Pain score in the fentanyl group had a significant decrease at 5-minute follow-up (P value=0.00). However, at 10, 30, and 60-minute follow-ups no significant differences were observed between the two groups in terms of pain score reduction. The rescue analgesia was required in 12 (7.7%) patients in the fentanyl group and in 48 (31.6%) patients in the morphine group (P value=0.00). No significant difference was observed regarding side effects, vital signs and patients' satisfaction between the two groups.

CONCLUSION

Fentanyl might be an effective and safe drug in opioid addicts suffering from ATLI.

The Evolving Landscape of Acute Pain Management in the Era of the Opioid Crisis

PURPOSE OF REVIEW

The purpose of the study is to evaluate and analyze the role of both opioid and non-opioid analgesics in the emergency department (ED).

RECENT FINDINGS

Studies have shown that the implementation of opioid-prescribing policies in the ED has the potential to reduce the opioid addiction burden. Clinical studies point to inconsistencies in providers' approach to pain treatment. In this review, we discuss specific aspects of opioid utilization and explore alternative non-opioid approaches to pain management. Pain is the most common reason patients present to the ED. As such, emergency medicine (EM) providers must be well versed in treating pain. EM providers must be comfortable using a wide variety of analgesic medications. Opioid analgesics, while effective for some indications, are associated with significant adverse effects and abuse potential. EM providers should utilize opioid analgesics in a safe and rational manner in an effort to combat the opioid epidemic and to avoid therapeutic misadventures. EM providers should be aware of all of their therapeutic options, e.g., opioid and non-opioid, in order to provide effective analgesia for their patients, while avoiding adverse effects and minimizing the potential for misuse.

Pain Assessment in Mechanically Ventilated, Noncommunicative Severe Trauma Patients

The aim of this study was to measure pain levels in noncommunicative patients with severe trauma who required tracheal suctioning and mobilization and to determine the utility of the Behavioral Indicators of Pain Scale (ESCID) in these cases. The pain scores for the procedures were recorded on Days 1, 3, and 6 of the patients' stay in the intensive care unit. These assessments were performed at 3 moments: before, during, and after the application of the procedures. Because of the longitudinal character of the study, data were fitted into a multivariate model using the Generalized Estimating Equations method. The sample of 124 patients comprised 77.4% males and 22.6% females with an average age of 45.93 (SD = 16.43) years. A significant increase (p < .01) in the ESCID score was observed during the application of the procedures that produced similar pain levels. Kappa coefficient value obtained for interobserver agreement of ESCID scale scores during the application of care procedures at the intervals being evaluated was greater than 0.84, which should be interpreted as almost perfect. The ESCID scores increased during 2 care procedures that are frequently carried out in intensive care units and indicated that they produced similar pain levels.

Pain Management in the Emergency Department: a Review Article on Options and Methods

CONTEXT

The aim of this review is to recognizing different methods of analgesia for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient's condition and to improve the quality of their services.

EVIDENCE ACQUISITION

In this review article, the search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane for emergency pain management methods were reviewed. Among the findings, high quality articles were eventually selected from 2000 to 2018, and after reviewing them, we have conducted a comprehensive comparison of the usual methods of pain control in the emergency department (ED).

RESULTS

For better understanding, the results are reported in to separate subheadings including "Parenteral agents" and "Regional blocks". Non-opioids analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of acute pain. However, the relief of acute moderate to severe pain usually requires opioid agents. Considering the side effects of systemic drugs and the restrictions on the use of analgesics, especially opioids, regional blocks of pain as part of a multimodal analgesic strategy can be helpful.

CONCLUSION

This study was designed to investigate and identify the disadvantages and advantages of using each drug to be able to make the right choices in different clinical situations for patients while paying attention to the limitations of the use of these analgesic drugs.

Fentanyl lozenge story part 2: from military procurement to package

This paper describes the selection of fentanyl as a replacement for morphine as the United Kingdom Ministry of Defence's first-line battlefield analgesic agent. It is a detailed review of the 6 year journey from selection to eventual roll-out in October 2017. It concentrates on the procurement and governance process of the deployment of fentanyl for individual issue and self-use. It highlights the significant differences in military and civilian legislation, the specialist environment we work in and the safety concerns surrounding controlled drugs in the austere environment. The lessons learnt can be applied to other organisations working in specialist environments that are looking to improve patient care through novel or off-license techniques that meet legislative resistance.

Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013

Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.

Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation

BACKGROUND

Prior research has documented the inadequacy of pain management for trauma patients in the emergency department (ED), with rates of pain assessment and opioid administration averaging about 50%. Such rates, however, may be misleading and do not adequately capture the complexity of pain management practices in a trauma population. The goal of the study was to determine if pain was undertreated at the study hospital or if patient acuity explained the timing and occurrence of pain treatment in the prehospital setting and the ED.

METHODS

A retrospective study was performed at a Level 1 adult trauma centre in the Midwest. The trauma registry was used to identify patients who received a trauma activation during the study period (June-November 2012; N=313). Using the first set of patient vitals and ISS, patients were grouped into three categories: physiologically stable with low injury severity (n=132); physiologically stable with moderate to severe injury (n=122); and physiologically unstable with severe injury (n=56). Differences were assessed with Kruskal-Wallis and chi-square tests.

RESULTS

Patients who were physiologically unstable were the least likely to receive a standardised pain assessment and the least likely to receive an opioid in the ED. Patients who were physiologically stable at entry to the ED but sustained a severe injury were the most likely to receive an opioid. Time to first pain assessment and time to first opioid did not differ by patient acuity.

CONCLUSIONS

Results confirm that patient acuity greatly affects the ability to effectively and appropriately manage pain in the initial hours after injury. This study contributes to the literature by noting areas for improvement but also in explaining why delaying pain treatment may be appropriate in certain patient populations.

Prehospital personnel’s attitudes to pain management

Objectives

Pain is one of the most common reasons for patients to seek acute medical care. The management of pain is often inadequate both in the prehospital setting and in the emergency department. Our aim was to evaluate the attitudes towards pain management among prehospital personnel in two Scandinavian metropolitan areas.

Methods

A questionnaire with 36 items was distributed to prehospital personnel working in Helsinki, Finland (n=70) and to prehospital personnel working in Stockholm, Sweden (n=634). Each item was weighted on a five-level Likert scale. Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Six scales were constructed (Hesitation, Encouragement, Side effects, Evaluation, Perceptions, Pain metre). A Student’s t-test, ANOVA, and Pearson Correlation were used for analysis of significance.

Results

: The response rate among the Finnish prehospital personnel was 66/70 (94.2%) while among the Swedish personnel it was 127/634 (20.0%). The prehospital personnel from Sweden showed significantly more Hesitation to administer pain relief compared to the Finnish personnel (mean 2.01 SD 0.539 vs. 1.67 SD 0.530, p < 0.001). Those who had received pain education at their workplace showed significantly less Hesitation than those who had not participated in education. There was a significant negative correlation (p < 0.01) between Hesitation and Side effects. There was also astatistically significant(p < 0.01) correlation between Perceptions and Hesitation, indicating that a stoic attitude towards pain was associated with indifference to possible Side effects of pain medication (p < 0.05).

Conclusions

The results show that there was a significant correlation between the extent of education and the prehospital personnel’s attitudes to pain management. Gender and age among the prehospital personnel also affected the attitudes to pain management. The main discrepancy between the Swedish and Finnish personnel was that the participants from Stockholm showed statistically significantly more hesitation about administering pain medication compared to the participants from Helsinki.

Implications

The results of the study highlight the need for continuous medical education (CME) for prehospital personnel. CME and discussions among prehospital personnel may help to make a change in the personnel’s attitudes towards pain and pain management in the prehospital context.

The role of the emergency pharmacist in trauma resuscitation

The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient's care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.

Intravenous Opioids for Severe Acute Pain in the Emergency Department

Objective:

To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy.

Data Sources:

Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department.

Study Selection and Data Extraction:

The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED.

Data Synthesis:

At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction.

Conclusions:

Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.