急诊医学创伤病人镇痛镇静的短平快临床研究

Background Acute trauma pain is poorly managed in the emergency department (ED). The reasons are partly organizational: ED crowding and rare trauma care pathways contribute to oligoanalgesia. Anticipating the organizational impact of an innovative care procedure might facilitate the decision-making process and help to optimize pain management. Methods We used a multiple criteria decision analysis (MCDA) approach to consider the organizational impact of methoxyflurane (self-administered) in the ED, introduced alone or supported by a trauma care pathway. A MCDA experiment was designed for this specific context, 8 experts in emergency trauma care pathways (leading physicians and pharmacists working in French urban tertiary hospitals) were recruited. The study involved four steps: (i) Selection of organizational criteria for evaluating the innovation’s impact; (ii) assessment of the relative weight of each criterion; (iii) choice of appropriate scenarios for exploring the organizational impact of MEOX under various contexts; and (iv) software-assisted simulation based on pairwise comparisons of the scenarios. The final outcome measure was the expected overall organizational impact of methoxyflurane on a 0-to-100 scale (score >50: positive impact). Results Nine organizational criteria were selected. "Mean length of stay in the ED" was the most weighted. Methoxyflurane alone obtained 59 as a total score, with a putative positive impact for eight criteria, and a neutral effect on one. When a trauma care pathway was introduced concomitantly, the impact of methoxyflurane was greater overall (score: 75) and for each individual criterion. Conclusions Our model highlighted the putative positive organizational impact of methoxyflurane in the ED—particularly when supported by a trauma care pathway—and the relevance of expert consensus in this particular pharmacoeconomic context. The MCDA approach could be extended to other research fields and healthcare challenges in emergency medicine.

To ascertain whether ear acupuncture (modified Battlefield technique) as an adjunct (Adj‐BFA) to standard analgesia care (SAC) significantly reduces pain scores compared with sham acupuncture (Adj‐Sham) or SAC alone, when delivered by medical and nursing practitioners in an ED.

BACKGROUND Opioids have been traditionally used for acute pain management; however, they are associated with side effects, including respiratory depression, physical dependence, and potential misuse. Ketamine is known to be an effective agent in reducing pain with side effects that have been shown to diminish with concurrent dexmedetomidine administration. OBJECTIVES The purpose of this study is to compare the use of ketamine-dexmedetomidine (K-D) with morphine for acute traumatic limb pain. METHODS In this single-center, randomized controlled trial, 258 adult patients who presented to the emergency department with acute limb trauma pain were examined. One group received intravenous (IV) ketamine (0.3 mg/kg) plus dexmedetomidine (0.5 mcg/kg), and the other group IV morphine (0.1 mg/kg). Pain, agitation scores, and side effects were compared between the two groups. Pain reduction at 30 min (primary outcome) was analyzed using independent t-test. RESULTS The mean pain score of patients in the K-D group was lower than the morphine group 30 min postinjection (K-D: 1.4 ± 2.3, morphine: 3.3 ± 2.3, p < 0.001). The need for rescue analgesic was 8.3% in the K-D group and 24% in the morphine (M) group. The mean agitation score in the ketamine group was higher during the first 10 min postinjection (K-D: 0.1 ± 0.6, p = 0.052, M: 0.0 ± 0.2, p = 0.002) but this was resolved by 30 min (K-D: 0.0 ± 0.3, p = 0.007, M: 0.0 ± 0.2, p = 0.006). CONCLUSION K-D controlled traumatic limb pain more effectively than morphine and was generally well tolerated. Our results suggest K-D may be a good alternative to opioids in controlling acute pain.

The vast majority of injured patients suffer from pain. Systematic assessment of pain on admission to the emergency department (ED) is a cornerstone of translating the best treatment strategies for patient care into practice. Pain must be measured with severity scales that are validated in clinical practice, including for specific populations (such as children and older adults). Although primary care ED of trauma patients focuses on resuscitation, diagnosis and treatment, pain assessment and management remains a critical element as professionals are not prepared to provide effective and early therapy. To date, most EDs have pain assessment and management protocols that take into account the patient’s hemodynamic status and clinical condition and give preference to non-pharmacological approaches where possible. When selecting medications, the focus is on those that are least disruptive to hemodynamic status. Pain relief may still be necessary in hemodynamically unstable patients, but caution should be exercised, especially when using opioids, as absorption may be impaired or shock may be exacerbated. The analgesic dose of ketamine is certainly an attractive option. Fentanyl is clearly superior to other opioids in initial resuscitation and treatment as it has minimal effects on hemodynamic status and does not cause central nervous system depression. Inhaled analgesia techniques and ultrasound-guided nerve blocks are also increasingly effective solutions. A multimodal pain approach, which involves the use of two or more drugs with different mechanisms of action, plays an important role in the relief of trauma pain. All EDs must have policies and promote the adoption of procedures that use multimodal strategies for effective pain management in all injured patients.

Chest trauma is a severe and frequent cause of admission to the emergency department (ED). The serratus anterior plane (SAP) block seems to be an effective method of pain management; however, data on efficacy and safety of a single SAP block performed in the ED by emergency physicians (EP) are limited. This study aimed to compare SAP block performed by the EP in the ED plus standard therapy to standard therapy alone in terms of pain severity at 0-3-6-12-18 and 24 h, total opioid consumption (milligrams of morphine equivalents, MME), respiratory function (SpO2/FiO2 ratio), and adverse events (i.e. pneumothorax, infections in the site of injection, or Local Anaesthetic Systemic Toxicity syndrome due to SAP block) in the first 24 h. This retrospective, monocentric study included adult patients admitted to the Sub-intensive Care Unit (SICU) of the ED with multiple rib fractures between 01/2022 and 03/2023. 156 patients (65.4% male; median age 62 years; median injury severity score 16; median thoracic trauma severity score 8) were included. 75 (48.2%) underwent SAP block. Patients undergoing SAP block showed significantly less pain 3–6–18 h after a single block, required less MME (0 [0–20] vs. 20 [0–40], p < 0.001), showed higher SpO2/FiO2 ratio, and no adverse events were reported. The SAP block, in combination with standard therapy, appeared to be more effective in providing pain relief than standard therapy alone in patients admitted to the SICU for traumatic rib fractures.

BackgroundParecoxib sodium is the first parenteral COX-2 inhibitor used for pain management licensed for postoperative pain. However, no study has assessed the usage of parecoxib for acute traumatic pain in the emergency department (ED). The objective of this study was to investigate a potential alternative analgesic agent in the ED by determining the mean reduction of pain score between acute traumatic pain patients who were administered with intravenous (IV) parecoxib sodium versus IV morphine sulfate. The onset of perceptible analgesic effect and side effects were also evaluated.MethodsA randomized, double-blinded study comparing IV parecoxib 40 mg versus IV morphine at 0.10 mg/kg was conducted in adult patients presented with acute traumatic pain with numeric rating scale (NRS) of 6 or more within 6 hours of injury. Patients were randomized using a computer-generated randomization plan. Drug preparation and dispensing were performed by a pharmacist. Periodic assessment of blood pressure, pulse rate, oxygen saturation, and NRS were taken at 0, 5, 15, and 30 minute intervals after the administration of the study drug. The primary outcome was the reduction of NRS. Side effect and drug evaluation was conducted within 30 minutes of drug administration.ResultsThere was no statistically significant difference in the reduction of mean NRS between patients in the IV parecoxib group or IV morphine group (P = 0.095). The mean NRS for patients treated with IV morphine were 7.1 at 0 minutes, 4.5 at 5 minutes, 3.1 at 15 minutes, and 2.0 at 30 minutes. Whereas mean NRS for patients who received IV parecoxib were 7.8 at 0 minutes, 5.7 at 5 minutes, 4.7 at 15 minutes, and 3.9 at 30 minutes. The onset of perceptible analgesic effects could be seen as early as 5 minutes. Dizziness was experienced in 42.9% of patients who received IV morphine compared to none in the parecoxib group.ConclusionsThere was non-significant trend toward superiority of IV morphine over IV parecoxib. Looking at its effectiveness and the lack of opioid-related side-effects, the usage of IV parecoxib sodium may be extended further to a variety of cases in the ED.

OBJECTIVE To systematically review the available data and scientific literature and to compile all evidence-related studies of the effectiveness of pain management for traumatic patients in the emergency department. METHODS The present study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS A total of 777 articles were retrieved, and eighteen were selected according to the inclusion criteria in this systemic review. These studies were published from 2004 to 2020 and reported from all around the world. Seventeen studies were based on pharmacological intervention, and one study was based on nonpharmacological intervention. Analgesics and methoxyflurane administration were the most adapted interventions for pain management in traumatic patients among the selected studies. Other reported interventions were fixed nitrous oxide/oxygen mixture, sufentanil, and professional practice assessment. CONCLUSION This systemic review provides an overview of the effectiveness of pharmacological and nonpharmacological pain management in trauma patients in the emergency department. Analgesic treatment is an effective and ancient management strategy with drawbacks of associated side effects and intravenous administration. New strategies reported and applied by oral or nasal route administration with similar and better efficacies. However, large-scale studies are crucial for better implementation and outcome. Nonpharmacological interventions may also contribute to pain relief.

Trauma is a major cause of mortality throughout the world. Traumatic pain—acute, sudden, or chronic—is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Patients’ perceptions of pain assessment and management have become an important criterion and relevant outcome measure for healthcare institutions. Several studies show that 60–70% of ER patients experience pain, and more than half of them express a feeling of sorrow, which can be moderate or severe, at triage. The few studies that have analyzed how pain is assessed and managed in these departments agree that approximately 70% of patients receive no analgesia or receive it with remarkable delay. Specifically, less than half of the patients receive treatment for pain during admission and 60% of discharged patients have higher intensity pain than at admission. Trauma patients are also the ones who most commonly report low satisfaction with pain management. Associated with this lack of satisfaction, we can describe the poor use of tools for measuring and recording pain, poor communication among caregivers, inadequate training in pain assessment and management, and widespread misconceptions among nurses about the reliability of patients’ estimation of pain. The aim of this article is to review the scientific literature to explore the methodologies of pain management in trauma patients attending the emergency room and analyzing their weaknesses as a starting point to improve the approach to this, unfortunately too often, underestimated issue. A literature search was performed using the major databases to identify relevant studies in indexed scientific journals. The literature showed that the multimodal approach in trauma patients is the best approach to pain management. It is becoming increasingly crucial to manage the patient on multiple fronts. Drugs acting on different pathways can be administered together at lower doses, minimizing risks. Every emergency department must have staff trained in the assessment and immediate management of pain symptoms as this allows the reduction of mortality and morbidity and shortens hospital stays, contributing to early mobilization, reduced hospital costs, and enhanced patient satisfaction and quality of life.

Children who sustain major injuries are at risk of receiving insufficient pain relief and sedation, which can have physical and psychological repercussions. Heightened emotional distress can increase the likelihood of developing symptoms of post-traumatic stress. Providing sufficient analgesia and sedation for children with major trauma presents specific challenges, given the potential for drug-related adverse events, particularly in non-intubated patients. The current literature suggests that a relatively low percentage of pediatric patients receive adequate analgesia in pre-hospital and emergency department settings following major trauma. There are only sparse data on the safety of the provision of analgesia and sedation in children with major trauma in the pre-hospital and ED settings. The few studies that examined sedation protocols in this context highlight the importance of physician training and competency in managing pediatric airways. There is a pressing need for prospective studies that focus upon pediatric major trauma in the pre-hospital and emergency department setting to evaluate the benefits and risks of administering analgesia and sedation to these patients. The aim of this narrative review was to offer an updated overview of analgesia and sedation management in children with major trauma in pre-hospital and ED settings.

Introduction A better understanding of current acute pain-driven analgesic practices within the emergency department (ED) and upon discharge will provide foundational information in this area, as few studies have been conducted in Canada. Methods Administrative data were used to identify adults with a trauma-related ED visit in the Edmonton area in 2017/2018. Characteristics of the ED visit included time from initial contact to analgesic administration, type of analgesics dispensed during and upon being discharged home directly from the ED (≤ 7 days after), and patient characteristics. Results A total of 50,950 ED visits by 40,505 adults with trauma were included. Analgesics were administered in 24.2% of visits, of which non-opioids were dispensed in 77.0% and opioids were dispensed in 49.0%. Time to analgesic initiation occurred more than 2 h after first contact. Upon discharge, 11.5% received a non-opioid and 15.2% received an opioid analgesic, among whom 18.5% received a daily dose ≥ 50 morphine milligram equivalents (MME) and 30.2% received > 7 days of supply. Three hundred and seventeen adults newly met criteria for chronic opioid use after the ED visit, among whom 43.5% received an opioid dispensation upon discharge; of these individuals, 26.8% had a daily dose ≥ 50 MME and 65.9% received > 7 days of supply. Conclusions Findings can be used to inform optimization of analgesic pharmacotherapy practices for the treatment of acute pain, which may include reducing the time to initiation of analgesics in the ED, as well as close consideration of recommendations for acute pain management upon discharge to provide ideal patient-centered, evidence-informed care.

Introduction: This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management. Methods: This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18‐year‐old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1 mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant. Results: Fifty patients with the mean age of 31.28 ± 8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on‐arrival mean pain scores in two groups were, lidocaine: 7.9 ± 1.4 and morphine: 8.0 ± 1.4 (p = 0.57) and after 1 hour were, lidocaine: 2.28 ± 1.2 and morphine: 3.2 ± 1.7. Although the pain score decreased significantly in both group (p = 0.027), there were not any clinically and statistically significant difference between the two groups (p = 0.77). Patients' satisfaction with pain management in both groups were almost similar (p = 0.49). Conclusion: The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.

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Importance: Legislation, practice recommendations, and the likely link between therapeutic opioid exposure and iatrogenic opioid use disorder (OUD) have led to reduced opioid prescribing. The effects of this change on unrelieved pain and the overdose crisis are not well-characterized. We explored emergency department (ED) patients’ beliefs and experiences involving pain and emergency care to inform the development of future psychosocial interventions that balance the need for acute pain management with risks from opioid exposure. Methods: Qualitative, semi-structured interviews were conducted after discharge from an urban, academic Level 1 trauma center ED from September 2020 to May 2021 with 18 adult patients presenting with acute pain. After transcription of audio recording, common themes were identified using framework analysis. Thematic hierarchy was validated with Pearson correlation coefficients for cluster analysis of word similarity. Results: Of the 18 participants, most were African American (n=11, 61%) and male (n=12, 66.7%). Analysis identified one overarching theme, Locus of control with an emergency pain encounter. Four themes were identified surrounding internal and external influences on pain management: 1) Accessing healthcare for acute pain; 2) Managing the pain after discharge; 3) Seeking opioids: self-medicating and misuse, and 4) Opioid crisis makes people in pain suffer. Conclusions: Patients discharged from the ED reported unrelieved pain, factors that influence their pain management, and an ability to seek opioids from non-medical sources. There is a significant disconnect between patients and providers in terms of priorities in pain management and the importance of individualized care.

BACKGROUND Management of pain from traumatic rib injury is very challenging. Both acute and chronic pain caused by rib injury can cause significant morbidity (pain-induced hypoventilation, pneumonia, respiratory failure) and functional hindrance. Traditional pain management strategies in the emergency department (ED) that target acute traumatic rib pain are limited by the side effects of medications or the temporary half-life of anesthetics used for a nerve block. Both treatment modalities fall short of addressing subsequent chronic sequelae. CASE REPORT We present the first-time use of cryoneurolysis on an ED patient for the treatment of 10/10 severe traumatic intercostal neuralgia that resulted in the patient being discharged home pain free. The patient initially underwent a multilevel left-sided T5-T7 intercostal nerve block, followed by ultrasound-guided percutaneous cryoneurolysis of those intercostal nerves using two cycles of 2 min of cooling to a temperature of -70°C (nitrous oxide), with 30 s of thawing in between. The patient experienced 100% pain relief immediately post procedure that was sustained. He remained completely symptom free more than 6 months after the bedside procedure and returned to sports without restrictions. Why Should an Emergency Physician Be Aware of This? This case highlights the benefits of cross-departmental collaboration between the ED, Anesthesia, and Pain Management. We hope this model of multidisciplinary pain modulation can be replicated for other patients with similar pain and can herald a new paradigm of pain management in the ED.

BackgroundProper pain assessment is a core component in management of trauma patients but prior literature has suggested that pain management is inadequate in emergency settings. With the development of emergency medicine in low-income countries (LIC), the procedures for pain assessment and management of trauma patients have not been well studied and protocols have not been established. We aimed to describe practices of pain assessment and management in an emergency department in Tanzania.MethodsThis was a prospective cohort study of consecutive adult trauma patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar es Salaam, Tanzania, from July 2017 to December 2017. A case report form (CRF) was used to record demographics and clinical characteristics of participants, whether or not pain was assessed at either triage or in the treatment area, and the administration of pain medications. The assistant also assessed pain independently with the numeric rating scale (NRS) of (0–10). Outcomes were proportions of patients who received pain assessment, patients who received pain medication, and types of medications administered. Descriptive data is summarised using frequency, percentage, and median with interquartile ranges as appropriate. Chi-square tests were used to determine association between pain assessments, receipt of pain medication, and types of medications.ResultsWe enrolled 311 (10.9%) trauma patients during the period of study. The median age was 32 years (IQR 25–43 years), and 228 (73.3%) were male. The most common mechanism of injury was motor vehicle crash 185 (59.4%), and of these, 87 (47%) involved motorcycles. Three hundred ten (99.6%) patients had pain assessment documented arrival, and 285 (91.6%) had a second assessment. Pain scores obtained by the research assistant were as follows: mild pain score (NRS 1–3) 154 (49.5%) patients, moderate pain (NRS 4–6) 68 (21.8%), and severe pain (NRS 7–10) 89 (28.7%). Pain medications were given to 144 (46.3%) patients, 29 (20.1%) of those with mild pain, 41 (28.7%) of those with moderate pain score, and 74 (51.4%) of those with severe pain. The use of opiates increased with increased pain severity.ConclusionsIn this ED in LIC, the assessment of pain was well documented; however, less than half of patients with documented pain received pain medication while at the ED. Future studies should focus on identification of factors affecting the provision of pain medications to trauma patients in the ED.

Purpose: This document describes the consensus process and intervention for a National Institutes of Health (NIH)-funded multi-site feasibility study utilizing acupuncture for ACUte paIn in The EmergencY Department (ACUITY). The acupuncture intervention is designed to be flexible and responsive to the most common Emergency Department (ED) scenarios, including trauma, acute pain of the low back, abdomen and/or musculoskeletal system, renal colic and headache. Background: Opioids remain a primary treatment for acute ED pain with attendant risk of adverse effects, addiction liability, diversion and death. Effective/safer options for acute pain are needed. Although acupuncture therapy has shown promise for acute pain in the ED alone or in conjunction with usual care, pragmatic trials are needed to obtain definitive and generalizable evidence. Methods: An Acupuncture Advisory Panel was convened that included nine acupuncture experts with 5–44 years of experience in practice and 2–16 years of experience in the acute pain care setting. A modified Delphi process was used with provision of a literature review, surveys of our panel members, three online discussions and email discussion as needed. The STandards for Reporting Interventions in Controlled Trials (STRICTA) checklist was used as a guide. Results: A responsive acupuncture intervention was agreed on for ACUITY. Session forms were fashioned in REDCap (Research Electronic Data Capture program to capture essential treatment data, assess fidelity and inform our design for a future pragmatic multi-site randomized controlled trial (RCT) of acupuncture in the ED, and for use by other future researchers. Conclusion: Development of a responsive manualization intervention provides the appropriate framework for conducting a future, pragmatic, multi-site, definitive RCT of acupuncture in the ED. Trial registration number: NCT04880733 (ClinicalTrials.gov).

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Rapid sequence intubation (RSI) is a common procedure within the Emergency Department. “Sedation gap”—the time between induction and post intubation sedation—has been associated with adverse outcomes. The aim of this study was to measure the median time to sedation or analgesia post intubation in adult patients within an Australian Emergency Department (ED). The secondary aim was to assess the difference in “sedation gap” among medical and trauma patient cohorts.

This comment critiques a trial comparing intranasal dexmedetomidine (DEX) and esketamine (sKET) for pediatric procedural sedation. Despite a large effect size, the small sample (n = 29) likely caused false-negative results (p = 0.09), necessitating larger trials. Safety concerns (e.g., aspiration risk), unaddressed long-term psychological outcomes, and limited pharmacokinetic data (delayed DEX onset, prolonged duration) challenge clinical applicability. Future studies should integrate objective measures and long-term follow-up.

Procedural sedation and analgesia are commonly used in the Emergency Departments. Despite this common need, there is still a lack of options for adequate and safe analgesia and sedation in children. The objective of this study was to evaluate whether intranasal dexmedetomidine could provide more effective analgesia and sedation during a procedure than intranasal esketamine. This was a double-blind equally randomized (1:1) superiority trial of 30 children aged 1–3 years presenting to the Emergency Department with a laceration or a burn and requiring procedural sedation and analgesia. Patients were randomized to receive 2.0 mcg/kg intranasal dexmedetomidine or 1.0 mg/kg intranasal esketamine. The primary outcome measure was highest pain (assessed using Face, Legs, Activity, Cry, Consolability scale (FLACC)) during the procedure. Secondary outcomes were sedation depth, parents’ satisfaction, and physician’s assessment. Comparisons were done using Mann–Whitney U test (continuous variables) and Fisher’s test (categorical variables). Adequate analgesia and sedation were reached in 28/30 patients. The estimated sample size was not reached due to changes in treatment of minor injuries and logistical reasons. The median (IQR) of highest FLACC was 1 (0–3) with intranasal dexmedetomidine and 5 (2–6.75) with intranasal esketamine, (p-value 0.09). 85.7% of the parents with children treated with intranasal dexmedetomidine were “very satisfied” with the procedure and sedation compared to the 46.2% of those with intranasal esketamine, (p-value 0.1). No severe adverse events were reported during this trial. This study was underpowered and did not show any difference between intranasal dexmedetomidine and intranasal esketamine for procedural sedation and analgesia in young children. However, the results support that intranasal dexmedetomidine could provide effective analgesia and sedation during procedures in young children aged 1–3 years with minor injuries. Trial registration: Eudra-CT 2017-00057-40, April 20, 2017. https://eudract.ema.europa.eu/

Procedural sedation and analgesia is an important part of pediatric emergency care, safe and clinically useful alternatives for adequate management are necessary. The objective of this clinical trial was to evaluate the non-inferiority of intranasal dexmedetomidine to nitrous oxide with respect to analgesia for a painful procedure in children 3–15 years of age. This prospective, equally randomized, open-label, non-inferiority trial was conducted at a Pediatric Emergency Department. Previously healthy children 3–15 years of age, with an extremity fracture or luxation or a burn and requiring procedural sedation and analgesia were eligible. Patients were randomized to receive either intranasal dexmedetomidine or inhaled nitrous oxide. The primary outcome measure was highest pain level during the procedure, assessed with Face, Legs, Activity, Cry, Consolability scale (FLACC). Mann-Whitney U test (continuous variables) and Fisher’s test (categorical variables) were used for statistical analysis. The highest FLACC was median 4 (IQR 3–6) with intranasal dexmedetomidine and median 4 (IQR 2–6) with nitrous oxide. The median of the difference between samples from each group for FLACC was 0 with 95%CI (0–1), thus intranasal dexmedetomidine was not inferior to nitrous oxide with respect to the level of pain during the procedure. The same method for procedural sedation and analgesia would be accepted by 52/74 (82.5%) children and 65/74 (91.5%) parents in the intranasal dexmedetomidine group respectively 59/74 (88.1%) versus 70/74 (94.6%) with nitrous oxide. No serious adverse events were reported. The results of this trial support that intranasal dexmedetomidine is not inferior to 50% nitrous oxide in providing analgesia for a painful procedure in children 3–15 years of age and can be considered as an alternative to 50% nitrous oxide for procedural sedation and analgesia. EudraCT 201,600,377,317, April 20, 2017. https://eudract.ema.europa.eu/.

In Vliet and colleagues’ research, the predominant patient cohort subjected to PSA and sedation consisted of trauma patients in the pre-hospital phase. It

Procedural sedation and analgesia (PSA) is a technique of administering sedatives to induce a state that allows the patient to tolerate painful procedures while maintaining cardiorespiratory function, a condition that is frequently desired prehospital. Non-physician prehospital clinicians often have a limited scope of practice when it comes to providing analgesia and sedation; sometimes resulting in a crew request for back-up from physician-staffed prehospital services.“. This is also the case if sedation is desirable. Advanced practice providers (APPs), who are legally authorized and trained to carry out this procedure, may be a solution when the physician-staffed service is not available or will not be available in time. The aim of this study is to gain insight in the circumstances in which an APP, working at the Dutch ambulance service “RAV Brabant MWN” from January 2019 to December 2022, uses propofol for PSA or to provide sedation. With this a retrospective observational document study we describe the characteristics of patients and ambulance runs and evaluates the interventions in terms of safety. During the study period, the APPs administered propofol 157 times for 135 PSA and in 22 cases for providing sedation. The most common indication was musculoskeletal trauma such as fracture care or the reduction of joint dislocation. In 91% of the situations where propofol was used, the predetermined goal e.g. alignment of fractured extremity, repositioning of luxated joint or providing sedation the goal was achieved. There were 12 cases in which one or more adverse events were documented and all were successfully resolved by the APP. There were no cases of laryngospam, airway obstruction, nor anaphylaxis. None of the adverse events led to unexpected hospitalization or death. During the study period, the APPs performed 135 PSAs and provided 22 sedations. The success rate of predetermined goals was higher than that stated in the literature. Although there were a number of side effects, their incidences were lower than those reported in the literature, and these were resolved by the APP during the episode of care. Applying a PSA by an APP at the EMS “RAV Brabant MWN” appears to be safe with a high success rate.

Acute pain is one of the most common symptoms in children admitted to the Pediatric Emergency Department (PED) and its management represents a real clinical challenge for pediatricians. Different painful procedures can be very stressful for young children and their perception of pain can be enhanced by emotional factors, such as anxiety, distress, or anger. Adequate procedural sedation reduces anxiety and emotional trauma for the patient, but it reduces also stress for operators and the time for procedures. We have reviewed the literature on this topic and the drugs covered in these papers were: midazolam, fentanyl, ketamine, and dexmedetomidine. There are several routes of administering for these drugs to provide analgesia and anxiolysis to children: oral, parenteral, or intranasal (IN). Intravenous (IV) sedation, since it involves the use of needles, can be stressful; instead, IN route is a non-invasive procedure and generally well tolerated by children and it has become increasingly widespread. Some medications can be administered by a mucosal atomizer device (MAD) or by drops. The benefits of the atomized release include less drug loss in the oropharynx, higher cerebrospinal fluid levels, better patient acceptability, and better sedative effects. IN midazolam has a sedative, anxiolytic and amnesic effect, but without analgesic properties. Fentanyl and ketamine are mainly used for pain control. Dexmedetomidine has anxiolytic and analgesic properties. In conclusion, IN analgo-sedation is a simple, rapid and painless option to treat pain and anxiety in the PED requiring brief training on the administration process and experience in sedation.

When compared with Ketamine alone for PSA in ED settings, the Ketofol with rapid onset of action, faster recovery time, cardio respiratory stability, less adverse events, and high patient satisfaction level make it a better option.

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Objective Many procedures performed in emergency department are stressful and painful, and creating proper and timely analgesia and early and effective assessment are the challenges in this department. This study has been conducted in order to compare the efficacy of propofol and fentanyl combination with propofol and ketamine combination for procedural sedation and analgesia (PSA) in trauma patients in the emergency department. Method This is a randomized prospective double‐blind clinical trial conducted in the emergency department of Imam Khomeini Hospital, a tertiary academic trauma center in northern Iran. Patients with trauma presenting to the emergency department who needed PSA were included in study. Patients were divided into two groups of propofol fentanyl (PF) and propofol ketamine (PK). Pain score and sedation depth were set as primary outcome measures and were recorded. Results Out of about 379 patients with trauma, who needed PSA, 253 met the criteria to be included in the study, 117 of which were excluded. The remaining 136 patients were randomly allocated to either PF group (n = 70) or PK group (n = 66). Pain management after drug administration was significantly different between the groups and the analgesia caused by fentanyl was significantly higher than ketamine. The sedation score after 15 min of PSA in the group PF was significantly higher than the group PK. Conclusion It seems that regarding PSA in the emergency department, PF caused better analgesia and deeper sedation and it is recommended to use PF for PSA in the emergency departments.

Procedural sedation and analgesia (PSA) is a core competency for emergency physicians (EP) that is commonly practiced. 1 – 4 PSA entails suppressing a patient’s level of consciousness with sedative or dissociative agents to alleviate pain, anxiety, and suffering to enhance medical procedure performance and patient experience (Table 22.1). 1 , 5

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Background Prehospital manipulation and reduction (M&R) of traumatic limb injuries may be required before transfer to restore alignment, reduce pain and bleeding, and limit secondary neurovascular compromise. In many systems this requires intravenous procedural sedation, which is resource-intensive and not universally available. Inhaled methoxyflurane (IMF) is a portable, self-administered analgesic used within UK HEMS, but its utility as the primary agent for prehospital M&R is not well described. Methods We performed a retrospective observational review of trauma patients attended by East Anglian Air Ambulance (1 January 2019 to 31 May 2023) who received IMF to facilitate prehospital M&R of an acute limb injury. The primary outcome was successful M&R using IMF without escalation to intravenous procedural sedation; failure was inability to reduce and/or subsequent intravenous procedural sedation. Multivariable logistic regression explored associations between success and age, sex, year, pre-reduction analgesia, and anatomical site. Data are reported as n (%), median [interquartile range], and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI); analyses were performed in R. Results Of 7765 patients attended, 788 received IMF and 309 met inclusion criteria. Median age was 48 [27–67] years and 160/309 (51.8%) were male. Successful M&R was achieved with IMF in 168/309 cases (54.4%); 127/141 (90.1%) failures required intravenous sedation. Increasing age (aOR 1.03 per year; 95% CI 1.02–1.05), prior opioid alone (aOR 2.50; 1.25–5.11) or opioid with paracetamol (aOR 2.19; 1.16–4.18), and patella injuries (aOR 30.12; 5.51–564.57) were independently associated with success, while femoral and tibia/fibula injuries had lower odds of success. No clinically important adverse events were recorded. Conclusions In this observational HEMS cohort selected for a trial of IMF, just over half of patients with acute traumatic limb injuries underwent prehospital manipulation and reduction without escalation to intravenous procedural sedation. Older age, pre-reduction analgesia, and patella injury were associated with success, but these findings are non-causal and should be interpreted cautiously. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-026-01591-8.

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Procedural sedation and analgesia (PSA) is an evolving field in pediatric emergency medicine. As new drugs breach the boundaries of anesthesia in the Pediatric Emergency Department, parents, patients, and physicians are finding new and more satisfactory methods of sedation. Short acting, rapid onset agents with little or no lingering effects and improved safety profiles are replacing archaic regimens. This article discusses the warning signs and areas of a patient's medical history that are particularly pertinent to procedural sedation and the drugs used. The necessary equipment is detailed to provide the groundwork for implementing safe sedation in children. It is important for practitioners to familiarize themselves with a select few of the PSA drugs, rather than the entire list of sedatives. Those agents most relevant to PSA in the pediatric emergency department are presented.

STUDY OBJECTIVE To evaluate if out-of-hospital administration of fentanyl and intranasal ketamine, compared to fentanyl alone, improves early pain control after injury. METHODS We conducted an out-of-hospital randomized, placebo-controlled, blinded, parallel group clinical trial from October 2017 to December 2021. Participants were male, aged 18 to 65 years, receiving fentanyl to treat acute traumatic pain prior to hospital arrival, treated by an urban fire-based emergency medical services agency, and transported to the region's only adult Level I trauma center. Participants randomly received 50 mg intranasal ketamine or placebo. The primary outcome was the proportion with a minimum 2-point reduction in self-described pain on the verbal numerical rating scale 30 minutes after study drug administration assessed by 95% confidence interval overlap. Secondary outcomes were side effects, pain ratings, and additional pain medications through the first 3 hours of care. RESULTS Among the 192 participants enrolled, 89 (46%) were White, (median age, 36 years; interquartile range, 27 to 53 years), with 103 receiving ketamine and 89 receiving placebo. There was no difference in the proportion experiencing improved pain 30 minutes after treatment (46/103 [44.7%] ketamine versus 32/89 [36.0%] placebo; difference in proportions, 8.7%; 95% confidence interval, -5.1% to 22.5%; P=.22) or at any time point through 3 hours. There was no difference in secondary outcomes or side effects. CONCLUSION In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients.

Importance Timely analgesia is critical for children with injuries presenting to the emergency department, yet pain control efforts are often inadequate. Intranasal administration of pain medications provides rapid analgesia with minimal discomfort. Opioids are historically used for significant pain from traumatic injuries but have concerning adverse effects. Intranasal ketamine may provide an effective alternative. Objective To determine whether intranasal ketamine is noninferior to intranasal fentanyl for pain reduction in children presenting with acute extremity injuries. Design, Setting, and Participants The Pain Reduction With Intranasal Medications for Extremity Injuries (PRIME) trial was a double-blind, randomized, active-control, noninferiority trial in a pediatric, tertiary, level 1 trauma center. Participants were children aged 8 to 17 years presenting to the emergency department with moderate to severe pain due to traumatic limb injuries between March 2016 and February 2017. Analyses were intention to treat and began in May 2017. Interventions Intranasal ketamine (1.5 mg/kg) or intranasal fentanyl (2 µg/kg). Main Outcomes and Measures The primary outcome was reduction in visual analog scale pain score 30 minutes after intervention. The noninferiority margin for this outcome was 10. Results Of 90 children enrolled, 45 (50%) were allocated to ketamine (mean [SD] age, 11.8 [2.6] years; 26 boys [59%]) and 45 (50%) to fentanyl (mean [SD] age, 12.2 [2.3] years; 31 boys [74%]). Thirty minutes after medication, the mean visual analog scale reduction was 30.6 mm (95% CI, 25.4-35.8) for ketamine and 31.9 mm (95% CI, 26.6-37.2) for fentanyl. Ketamine was noninferior to fentanyl for pain reduction based on a 1-sided test of group difference less than the noninferiority margin, as the CIs crossed 0 but did not cross the prespecified noninferiority margin (difference in mean pain reduction between groups, 1.3; 90% CI, −6.2 to 8.7). The risk of adverse events was higher in the ketamine group (relative risk, 2.5; 95% CI, 1.5-4.0), but all events were minor and transient. Rescue analgesia was similar between groups (relative risk, 0.89; 95% CI, 0.5-1.6). Conclusions and Relevance Ketamine provides effective analgesia that is noninferior to fentanyl, although participants who received ketamine had an increase in adverse events that were minor and transient. Intranasal ketamine may be an appropriate alternative to intranasal fentanyl for pain associated with acute extremity injuries. Ketamine should be considered for pediatric pain management in the emergency setting, especially when opioids are associated with increased risk. Trial Registration ClinicalTrials.gov Identifier: NCT02778880

BACKGROUND Peripheral vasoconstriction is the most critical compensating mechanism following hemorrhage to maintain blood pressure. On the battlefield, ketamine rather than opioids is recommended for pain management in case of hemorrhage but effects of analgesics on compensatory vasoconstriction are not defined. We hypothesized that fentanyl impairs but ketamine preserves the peripheral vasoconstriction and blood pressure compensation following hemorrhage. METHOD Sprague Dawley rats (11-13wk) were randomly assigned to control (saline vehicle), fentanyl, or ketamine-treated groups with or without hemorrhage (n = 8 or 9 for each group). Rats were anesthetized with Inactin (ip. 10mg/100g) and the spinotrapezius muscles were prepared for microcirculatory observation. Arteriolar arcades were observed with a Nikon microscope and vessel images and arteriolar diameters (AD) were recorded by using Nikon NIS Elements Imaging Software. After baseline perimeters were recorded, the arterioles were topically challenged with saline, fentanyl, or ketamine at concentrations relevant to intravenous analgesic doses to determine direct vasoactive effects. After arteriolar diameters returned to baseline, 30% of total blood volume was removed in 25 min. Ten minutes after hemorrhage, rats were intravenously injected with an analgesic dose of fentanyl (0.6μg/100g), ketamine (0.3mg/100g), or a comparable volume of saline. For each drug or vehicle administration, the total volume injected was 0.1 ml/100g. Blood pressure, heart rate, and arteriolar responses were monitored for 40 minutes. RESULTS Topical fentanyl induced vasodilation (17 ± 2%) but ketamine caused vasoconstriction (-15 ± 4%, p < 0.01). Following hemorrhage, intravenous ketamine did not affect blood pressure or respiratory rate, while fentanyl induced a slight and transient (<5 min, p = 0.03 vs saline group) decrease in blood pressure, with a profound and prolonged suppression in respiratory rate (>10 minutes, with a peak inhibition of 57 ± 8% of baseline, p < 0.01). The compensatory vasoconstriction observed after hemorrhage was not affected by ketamine treatment. However, after fentanyl injection, although changes in blood pressure were transiently present, arteriolar constriction to hemorrhage was absent and replaced with a sustained vasodilation (78 ± 25% to 36 ± 22% of baseline during the 40 minutes after injection, p < 0.01). CONCLUSION Ketamine affects neither systemic nor microcirculatory compensatory responses to hemorrhage, providing preclinical evidence that ketamine may help attenuate adverse physiological consequences associated with opioids following traumatic hemorrhage. Microcirculatory responses are more sensitive than systemic response for evaluation of hemodynamic stability during procedures associated with pain management.

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BACKGROUND Pain management is important in prehospital care of patients with extremity trauma (ET). The goal of this study was to establish a rat model of ET for prehospital pain research and validate it using pain behaviors and analgesics. METHODS Rats were anesthetized using isoflurane, and ET was induced in one hindlimb via clamping retrofemoral tissues for 30 seconds, followed by closed fibula fracture. Rats regained consciousness after ET. Pain responses in the injured hindlimb to thermal hyperalgesia (paw withdrawal latency [PWL]), mechanical allodynia (paw withdrawal pressure [PWP]), and weight bearing (WB) were determined before and 90 minutes after ET. Morphine (2 mg/kg), fentanyl (10 &mgr;g/kg), sufentanil (1 &mgr;g/kg), ketamine (5 mg/kg), or vehicle (saline) were then administered via intravenous (i.v.) injection, followed by PWL, PWP, and WB assessments at 10 minutes, 40 minutes, 80 minutes, and 120 minutes after analgesia. RESULTS After ET, PWL, PWP, and WB were significantly decreased by 61 ± 4%, 64 ± 8%, and 65 ± 4%, respectively, compared with pre-ET values. These pain behaviors were maintained for 3 hours to 4 hours. Compared with the saline group, opioid analgesics significantly increased PWL for at least 80 minutes, with sufentanil exhibiting the highest analgesic effect. An increase in PWL was only observed at 10 minutes after ketamine. The PWP was transiently increased with opioid analgesics for 10 minutes to 40 minutes, but was not changed with ketamine. Weight bearing was improved with opioid analgesics for at least 2 hours, but only for up to 80 minutes with ketamine. CONCLUSION Our ET model includes long bone fracture and soft tissue injury, but no fixation surgery, mimicking prehospital ET. Our model produces acute, steady, and reproducible trauma-related pain behaviors, and is clinically relevant regarding the pain behaviors and established responses to common analgesics. This model of acute pain due to ET is ideal for prehospital pain management research.

BACKGROUND Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF. METHODS All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided. RESULT Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6–16%, p < 0.001). CONCLUSION Pain management has become more common in trauma patients’ prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall. LEVEL OF EVIDENCE Therapeutic/care management, level III.

Introduction Burns are a common trauma that cause acute severe pain in up to 80% of patients. The objective of this narrative review is to evaluate the efficacy of opioids, non-steroidal anti-inflammatory drugs, paracetamol, gabapentinoids, ketamine, and lidocaine in the treatment of acute pain in burn victims. Methodology The databases explored were PubMed, Embase, ClinicalTrials, and OpenGrey. The included randomized, controlled clinical trials assessed the analgesic efficacy of these drugs on hospitalized patients, had no age limit, patients were in the acute phase of the burn injury and were compared to placebo or other analgesic drugs. Studies describing deep sedation, chronic opioid use, chronic pain, and patients taken to reconstructive surgeries were excluded. The Jadad scale was used to evaluate quality. Results Six randomized controlled clinical trials (397 patients) that evaluated the analgesic efficacy of fentanyl (n = 2), nalbuphine (n = 1), ketamine (n = 1), gabapentin (n = 1), and lidocaine (n = 1) to treat post-procedural pain were included. Fentanyl, nalbuphine, and ketamine were effective, while lidocaine was associated with a slight increase in reported pain and gabapentin showed no significant differences. Two studies were of high quality, one was of medium high quality, and three were of low quality. No studies on the efficacy of NSAIDs or paracetamol were found. Conclusion Evidence of efficacy is very limited. Fentanyl, nalbuphine, and ketamine seem to be effective for controlling acute pain in burn patients, whereas gabapentin and lidocaine did not show any efficacy.

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In a pragmatic randomized clinical trial, a sub-dissociative ketamine infusion was associated with a reduction in hospital opioid exposure with similar or improved pain scores. #TraumaSurg #painmanagment #opioidcrisis #ketamine BACKGROUND Non-narcotic intravenous medications may be a beneficial adjunct to oral multimodal pain regimens (MMPRs) which reduce but do not eliminate opioid exposure and prescribing after trauma. We hypothesized that the addition of a subdissociative ketamine infusion (KI) to a standardized oral MMPR reduces inpatient opioid exposure. METHODS Eligible adult trauma patients admitted to the intermediate or intensive care unit were randomized upon admission to our institutional MMPR per usual care (UC) or UC plus subdissociative KI for 24 hours to 72 hours after arrival. The primary outcome was morphine milligram equivalents per day (MME/d) and secondary outcomes included total MME, discharge with an opioid prescription (OP%), and rates of ketamine side effects. Bayesian posterior probabilities (pp) were calculated using neutral priors. RESULTS A total of 300 patients were included in the final analysis with 144 randomized to KI and 156 to UC. Baseline characteristics were similar between groups. The Injury Severity Scores for KI were 19 [14, 29] versus UC 22 [14, 29]. The KI group had a lower rate of long-bone fracture (37% vs. 49%) and laparotomy (16% vs. 24%). Patients receiving KI had an absolute reduction of 7 MME/day, 96 total MME, and 5% in OP%. In addition, KI had a relative risk (RR) reduction of 19% in MME/day (RR, 0.81 [0.69–0.95], pp = 99%), 20% in total MME (RR, 0.80 [0.64–0.99], pp = 98%), and 8% in OP% (RR, 0.92 [0.76–1.11], pp = 81%). The KI group had a higher rate of delirium (11% vs. 6%); however, rates of other side effects such as arrythmias and unplanned intubations were similar between groups. CONCLUSION Addition of a subdissociative ketamine infusion to an oral MMPR resulted in a decrease in opioid exposure in severely injured patients. Subdissociative ketamine infusions can be used as a safe adjunct to decrease opioid exposure in monitored settings. LEVEL OF EVIDENCE Therapeutic/Care Management; Level I.

During point-of-injury and en route care, pain after traumatic injuries is frequently treated with parenteral fentanyl. Ketamine is increasingly used and may offer opioid-sparing effects, but the dose of ketamine recommended by Tactical Combat Casualty Care (TCCC), and the combination with fentanyl, is inadequately studied. Combination therapy may offer longer-lasting analgesia, even if initial pain relief is no different. Early pain management with ketamine may decrease the risk of developing posttraumatic stress disorder (PTSD) symptoms and chronic pain, but these long-term benefits are unconfirmed. This prehospital trial evaluates if fentanyl and intranasal ketamine, compared to fentanyl alone, improves early analgesia after injury, increases the duration of adequate analgesia, and decreases the rate of developing symptoms of PTSD or chronic pain. This abstract includes, and builds upon, previously published work. 1 We conducted a prehospital randomized, placebo-controlled, blinded, parallel group clinical trial between October 2017 and December 2021. Detailed methods have been published. 2 Paramedics of an urban, fire department-based EMS agency in the United States screened, consented, and enrolled men, ages 18–65 years, who received fentanyl to treat acute traumatic pain during transport to the region’s only adult Level I Trauma Center. Of 569 eligible participants, 199 were randomized, and 192 underwent primary analysis. Participants received 50mg intranasal ketamine or a matching volume (1mL) of placebo. Fentanyl route and dose was determined by the treating paramedic. All other prehospital and emergency department treatments were at clinician discretion. The primary outcome was a two-point reduction in self-described pain on the Verbal Numerical Rating Scale thirty minutes after intervention. Secondary outcomes were pain control and additional pain medications through the first three hours of care. Exploratory outcomes included development of PTSD and chronic pain at 90-days. Analyses used descriptive statistics and Chi-square testing. 192 men, 89 (46%) White, 36 [27, 53] (median [IQR]) years old were included; 27% suffered penetrating injury, 5% had an Injury Severy Score >15, and 14% were taken directly to the operating room from the emergency department. 103 received ketamine and 89 received placebo, with no statistical difference in the proportion experiencing improved pain 30 minutes after treatment (figure 1; 45% ketamine vs. 36% placebo) or at any timepoint through 180 minutes. The proportion requiring additional pain medications or experiencing side effects through three hours were similar. Of 154 participants consenting for follow-up, 96 (54 ketamine, 42 placebo) completed the 90-day assessments, with no difference in the proportion developing PTSD (18% placebo vs. 14% ketamine) or chronic pain at follow-up. Adding 50mg intranasal ketamine to fentanyl prior to hospital arrival did not improve early analgesia or reduce the risk of developing symptoms of PTSD or chronic pain at 90-day follow-up. TCCC has updated intranasal ketamine dosing recommendations to 100mg, which may be more effective. Abstract P02 Figure 1 Absolute change from baseline stated verbal numerical rating scale, assessed 30-minutes after receiving study drug. The central parallel line plot shows the VNRS for each participant at baseline and 30 minutes after receiving study drug. The box-whisker plots demonstrate within- and between-group differences. (P: placebo; K: ketamine) (Used with permission from McMullan et al.1) McMullan JT, Droege CA, Chard KM, Otten EJ, Hart KW, Lindsell CJ, Strilka RJ. Out-of-hospital intranasal ketamine as an adjunct to fentanyl for the treatment of acute traumatic pain: a randomized clinical trial. Ann Emerg Med . 2024 Oct; 84 (4):363–373. doi: 10.1016/j.annemergmed.2024.04.018. McMullan J, Droege C, Strilka R, Hart K, Lindsell C. Intranasal ketamine as an adjunct to fentanyl for the prehospital treatment of acute traumatic pain: design and rationale of a randomized controlled trial. Prehosp Emerg Care . 2021 Jul-Aug; 25 (4):519–529. doi: 10.1080/10903127.2020.1808746.

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Background Evidence for effective pain management and opioid minimization of intravenous ketamine in elective surgery has been extrapolated to acutely injured patients, despite limited supporting evidence in this population. This trial seeks to determine the effectiveness of the addition of sub-dissociative ketamine to a pill-based, opioid-minimizing multi-modal pain regimen (MMPR) for post traumatic pain. Methods This is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing a MMPR to a MMPR plus a sub-dissociative ketamine infusion. All trauma patients 16 years and older admitted following a trauma which require intermediate (IMU) or intensive care unit (ICU) level of care are eligible. Prisoners, patients who are pregnant, patients not expected to survive, and those with contraindications to ketamine are excluded from this study. The primary outcome is opioid use, measured by morphine milligram equivalents (MME) per patient per day (MME/patient/day). The secondary outcomes include total MME, pain scores, morbidity, lengths of stay, opioid prescriptions at discharge, and patient centered outcomes at discharge and 6 months. Discussion This trial will determine the effectiveness of sub-dissociative ketamine infusion as part of a MMPR in reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will inform decisions regarding acute pain strategies on patient centered outcomes. Trial registration The Ketamine for Acute Pain Management After Trauma (KAPT) with registration # NCT04129086 was registered on October 16, 2019.

Background Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury. Methods A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes. Discussion The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia. Trial registration : ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474

BackgroundEvidence for effective pain management and opioid minimization of intravenous ketamine in elective surgery has been extrapolated to acutely injured patients, despite limited supporting evidence in this population. This trial seeks to determine the effectiveness of the addition of sub-dissociative ketamine to a pill-based, opioid-minimizing multi-modal pain regimen (MMPR) for post traumatic pain.MethodsThis is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing a MMPR to a MMPR plus a sub-dissociative ketamine infusion. All trauma patients 16 years and older admitted following a trauma which require intermediate (IMU) or intensive care unit (ICU) level of care are eligible. Prisoners, patients who are pregnant, patients not expected to survive, and those with contraindications to ketamine are excluded from this study. The primary outcome is opioid use, measured by morphine milligram equivalents (MME) per patient per day (MME/patient/day). The secondary outcomes include total MME, pain scores, morbidity, lengths of stay, opioid prescriptions at discharge, and patient centered outcomes at discharge and six months.DiscussionThis trial will determine the effectiveness of sub-dissociative ketamine infusion as part of a MMPR in reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will inform decisions regarding acute pain strategies on patient centered outcomes.Trial Registration:The Ketamine for Acute Pain Management After Trauma (KAPT) with registration # NCT04129086 was registered on 10/16/2019 and is available at https://clinicaltrials.gov/ct2/show/NCT04129086?term=ketamine+injury&draw=2&rank=6

BACKGROUND Chronic pain, anxiety, depression, and posttraumatic stress disorder (PTSD) are frequently seen after traumatic injury. Ketamine infusions used to treat acute pain may decrease the risk of chronic pain and improve psychological outcomes of injured patients. We hypothesized patients receiving ketamine would have a lower incidence of chronic pain, anxiety, depression, and PTSD. METHODS A prospective, randomized, double-blind placebo-controlled trial of severely injured (Injury Severity Score ≥15) adult patients (age, 18-64 years) admitted to a Level 1 trauma center was conducted. Exclusion criteria included pregnancy and chronic opiate use. All patients were prescribed a patient-controlled analgesia and randomized to either adjustable dose ketamine (ADK) starting at 3 μg/kg/min or an equivalent rate of 0.9% normal saline. Quality of life (QoL) outcomes were measured using Depression and Anxiety (Depression Anxiety Stress Scales 21), PTSD (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5), Trauma quality of life (TQOL), and pain (Brief Pain Inventory-Short Form) questionnaires at hospitalization, and 1, 3, and 6 months postdischarge. Linear regression analysis evaluated the relationship between groups and baseline pain and mental health outcomes at each follow-up. RESULTS Forty-four of 82 patients (54%) were randomized to ADK. Both groups were similar in demographics, injury mechanisms/severity, and baseline QOL measures. Patients in the ketamine group had significantly less anxiety symptom severity (p < 0.05) and PTSD (p < 0.05), with significantly less re-experiencing symptoms (subscale of PTSD) at 3 and 6 months (p < 0.05). CONCLUSION Ketamine infusion for acute pain treatment in severe traumatic injury may significantly reduce anxiety and PTSD 6 months after injury. This effect may be specific to the memory processes responsible for re-experiencing symptoms. Further research should explore the effects of acute ketamine administration on the neurobiological mechanisms implicated in the development of PTSD, as this could be a novel preventative intervention to improve QoL for injured patients. LEVEL OF EVIDENCE/STUDY TYPE Level 1, Therapeutic/Care Management.

Objectives Pediatric patients with extremity fractures often require sedation for fracture reduction in the pediatric emergency department (PED). Although orthopedic literature suggests combination sedation regimens may be more effective for fracture reduction, some pediatric literature suggests adverse events are more frequent. The primary objective of this study is to determine the comparable depth of sedation and incidence of adverse events when intravenous ketamine is used alone versus with midazolam for pediatric procedural sedation and orthopedic fracture reduction. Methods This is a retrospective cohort study of pediatric patients 2–18 years old who underwent sedation for fracture reduction in the PED at a single level 1 trauma center over a 2-year period. Medical records were reviewed, and occurrence of adverse events, depth of sedation (Ramsey score), midazolam dose, total ketamine administration, opiate administration, total sedation time, and time to PED discharge were compared in patients who received ketamine alone versus those who received ketamine with midazolam. Logistic regression models were adjusted to evaluate for potential confounders. Results There was a statistically significant increase in the occurrence of hypoxia with coadministration of midazolam (5% vs 0%). When hypoxia occurred, it was mild and resolved with repositioning or administration of supplemental oxygen. Length of sedation was increased in sedations with coadministration of benzodiazepines by approximately 3.5 minutes. Time to PED discharge was not significantly different. There was no significant difference in depth of sedation, ketamine dose administered, end-tidal CO2 measurements, administration of positive pressure ventilation, vomiting, agitation, or overall occurrence of adverse events. No patients developed apnea or laryngospasm. Conclusions This study showed a low rate of adverse events in pediatric sedation for orthopedic reduction with ketamine alone or ketamine with midazolam. There was an increased occurrence of hypoxia with coadministration of midazolam and an increase in the length of sedation. This study showed no difference in depth of sedation based on Ramsay scores when midazolam was coadministered. Information on the orthopedic reduction and provider satisfaction was not collected.

BACKGROUND/AIMS Ketamine sedation has not been reported to be widely used as a pharmacological behavioural management strategy to facilitate the treatment of acute paediatric oro-dental trauma. The aim of this study was to investigate the safety and effectiveness of intramuscular ketamine sedation for managing paediatric oro-dental trauma in a paediatric Emergency Department (ED). METHODS The database of all paediatric procedural sedations performed in the hospital ED from 01 January 2014 to 31 December 2016 was reviewed to identify cases where intramuscular ketamine sedation was administered for dentists' treatment of oro-dental trauma. Patient demographics and epidemiological data, the type and number of sedation-related adverse events, and interventions performed were extracted from the database. Clinical notes were reviewed to verify the dental diagnoses and dental treatment performed. Adverse events were further risk stratified using the World SIVA adverse event reporting tool. RESULTS In the study period, 167 intramuscular ketamine sedations were administered by ED doctors for dental treatment of oro-dental trauma. The patients' median age was 3.6 years (range 1.1 to 12 years). All dental procedures were successfully completed. Nineteen adverse events were reported (11.4%, n=19) with the most common being emesis (9.0%) followed by transient desaturation (1.8%) and hypersalivation (0.6%). The lowest oxygen saturation level was 90%. None of the patients aspirated, and none required assisted ventilation or chest compression. The most common dental diagnosis was primary tooth luxation (49.1%). The most common dental treatment was primary teeth extraction (70.7%). When adverse events were stratified using the World SIVA tool, there were only 17 (10.2%) minor risk outcomes. CONCLUSIONS The data support the safety and effectiveness of intramuscular ketamine sedation administered by trained ED doctors to facilitate the management of paediatric oro-dental trauma emergencies. This article is protected by copyright. All rights reserved.

Effective acute pain management in the emergency department is essential, especially for patients with fractures, dislocations, and other musculoskeletal injuries. Conventional approaches like systemic opioids and procedural sedation, while commonly used, can lead to side effects such as respiratory issues, nausea, extended emergency department stays, and potential opioid dependence. In recent years, ultrasound-guided nerve blocks have gained attention as a safer and more targeted method of pain control that can reduce reliance on opioids. This review explored how ultrasound-guided nerve blocks compare to traditional pain management strategies in terms of effectiveness, safety, and clinical outcomes. A detailed search was conducted across several major medical databases, including PubMed, Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and the Virtual Health Library. Search terms focused on ultrasound, anesthesia, nerve blocks, and emergency care. The review included only randomized controlled trials published in English that involved adult patients receiving ultrasound-guided nerve blocks for acute pain in emergency settings. The main outcomes assessed were pain relief (measured using validated scales), opioid use, time spent in the emergency department, patient satisfaction, and adverse events. Out of 3,299 studies initially identified, 2,430 remained after removing duplicates. After reviewing 60 full-text articles, nine met the inclusion criteria for analysis. The results showed that ultrasound-guided nerve blocks provided more rapid and sustained pain relief than standard treatments, with a noticeable reduction in opioid use. They were also linked to shorter emergency department stays, higher levels of patient satisfaction, and a low rate of complications when carried out by trained providers. These findings suggest that ultrasound-guided nerve blocks can be a highly effective first-line option for managing acute pain in trauma patients. Still, further studies are recommended to optimize their use and encourage broader implementation in emergency care settings.

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Background: Initial treatment for a displaced ankle fracture is closed reduction and splinting. This is typically performed in conjunction with either an intra-articular hematoma block (IAHB) or procedural sedation (PS) to assist with pain control. The purpose of this study was to compare the safety of IAHB to PS and evaluate the efficiency and efficacy for each method. Methods: A retrospective chart review for ankle fractures requiring manipulation was performed for patients seen in a level I trauma center from 2005 to 2016. The primary outcome was rate of successful reduction. Several secondary outcome measures were defined: reduction attempts, time until successful reduction, time spent in the emergency department (ED), rate of hospital admission, and adverse events. The analysis included 221 patients who received IAHB and 114 patients who received PS. Results: The demographics between the 2 groups were similar, with the exception that more patients with a dislocation received PS, which prompted a subgroup analysis. This analysis demonstrated that patients with an ankle fracture and associated tibiotalar joint subluxation underwent closed reduction in a shorter period of time with the use of an IAHB compared with those receiving PS. In patients sustaining a tibiotalar fracture dislocation, patients receiving PS were successfully reduced with 1 reduction attempt more frequently than those receiving IAHB. Orthopedic surgeons also had higher rates of success on first attempt compared with ED providers. Conclusion: Both IAHB and PS were excellent options for analgesia that resulted in high rates of successful closed reduction of ankle fractures with adequate safety. IAHB can be considered a first-line agent for patients with an ankle fracture and associated joint subluxation. Level of Evidence: Level III, retrospective comparative series.

Results 386 patients were enrolled over 18 months. The median age was 57 (IQR 38-70) years, 55% were male. All had ASA class score ≤ 3. Indications for procedural sedation were reduction of dislocations (52%), electro-cardioversion (32%), fracture reduction (9%) and abscess/wound treatment (6%). The median propofol dose was 1.0 mg/kg (0.70-1.5) and 44% also received fentanyl; median dose 1 mcg/kg (0.6-1.3). Most had a Ramsay sedation score of 4 or 5 (54%). The procedural success rate was 99.5%. No serious adverse events were reported. Sedation events included; hypoventilation (11%), desaturation (5%), hypotension (3%) and bradycardia (1%), all of which resolved with simple supportive interventions. One patient vomited without aspirating. Increased age (p = 0.001) and high Ramsey score (> 3) (p = 0.024) were the only significant predictors of events. Gender, weight, total dose of propofol, use of fentanyl and type of procedure were not independent risk factors for any event. Conclusion Procedural sedation with propofol can be performed safely and effectively by newly trained Dutch emergency physicians. Increased age and high Ramsay scores were the only risk factor for sedation events. All events were minor and responded to simple interventions. Possibly this study can aid the introduction of procedural sedation with propofol by emergency physicians in other countries where emergency medicine is a new and upcoming specialty.

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Prolonged Field Care (PFC) refers to the delivery of advanced trauma care in austere environments when evacuation to definitive treatment is significantly delayed. Although originally developed within military medicine, its principles are increasingly relevant to civilian trauma systems operating in remote, rural, wilderness, disaster, and resource-limited settings. This narrative review provides an updated overview of PFC concepts and their potential applicability to civilian trauma care, focusing on key domains such as airway management, haemorrhage control, crush syndrome, analgesia and sedation, and telemedicine-supported decision-making. Current evidence suggests that PFC may provide a practical and flexible framework to maintain physiological stability, prevent secondary complications, and support clinical decision-making during prolonged rescue scenarios. Telemedicine may further enhance procedural safety and diagnostic capability in isolated settings. Despite the predominance of military-derived evidence, several PFC principles may be adaptable to selected civilian emergency systems, although important operational and logistical differences must be considered. Further research is needed to evaluate outcomes and support context-specific implementation in civilian practice.

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Background: Procedural sedation in children continues to be a problem in the emergency department (ED). Midazolam is the first water-soluble benzodiazepine and it has been widely used for procedural sedation in pediatric patients. Objectives: The aim of this study was evaluation of clinical safety and effectiveness of intramuscular Midazolam for pediatric sedation in the ED setting. Materials and Methods: We performed a self-controlled clinical trial on 30 children who referred to the Baqiyatallah Hospital ED between 2009 and 2010. They received intramuscular Midazolam 0.3 mg/kg for procedural sedation and then they were followed for sedative effectiveness and safety. Vital signs and O2 saturation were also observed. The findings were compared using SPSS ver. 16 software. Results: The mean age was 5.50 ± 2.70 years, the mean weight was 19.50 ± 6.63 kilograms and 16 patients (53.3%) were females. The most common adverse effect was euphoria (66.66%) and vertigo (6.7%); 27.7% did not show any side effects. There was an overall complication rate of 72.3%. The vital signs including heart rate, respiratory rate, systolic and diastolic blood pressure and O2 saturation decreased significantly during sedation (P value < 0.05). Conclusions: Midazolam is an effective and relatively safe sedative for pediatric patients in the ED. The patient should be observed closely and monitored for psychological and hemodynamic side effects.

BACKGROUND Venipuncture for intravenous access is a frequent and distressing procedure in pediatric hospitals and trauma centers. Achieving immobility in young, anxious children is essential yet difficult. A direct comparison of commonly used sedatives for this purpose was lacking. OBJECTIVE To directly compare the efficacy and safety of oral chloral hydrate versus midazolam for facilitating successful venipuncture in hospitalized children aged 1-5 years in emergency and trauma care. METHODS Prospective, double-blind, randomized trial in a tertiary hospital emergency department. One hundred children received either oral chloral hydrate (50 mg/kg) or oral midazolam (0.3 mg/kg) 30 min before venipuncture. PRIMARY OUTCOME number of attempts for successful venipuncture. Secondary outcomes included sedation time, venipuncture duration, total procedural time, recovery time, satisfaction, and adverse events. Analyses were adjusted for baseline age and weight differences. RESULTS Chloral hydrate significantly reduced the number of venipuncture attempts (1.30 vs. 1.96; mean difference -0.66, 95% CI: -0.92 to -0.40, p < 0.001). Time to adequate sedation (16.30 vs. 25.54 min), IV access time (6.80 vs. 16.74 min), and total procedural time (42.12 vs. 67.06 min) were all significantly shorter with chloral hydrate (all p < 0.001). Recovery time did not differ (p = 0.819). After adjustment for age and weight, all efficacy outcomes remained superior for chloral hydrate. Parent and nurse satisfaction were significantly higher with chloral hydrate. Safety profiles were comparable, with stable vital signs and low, similar rates of minor adverse events. CONCLUSION Oral chloral hydrate is significantly more effective than oral midazolam for sedating children during venipuncture in emergency and trauma settings, without compromising safety. Chloral hydrate should be considered a preferred agent for this indication.

Purpose: Pain management in orthopaedic manipulation in the emergency department (ED) is crucial to decrease fracture reduction performed in the operating room. This study compared intranasal fentanyl (INF) with oral morphine in time of care and effectiveness on pain during the reduction of bone fractures in a pediatric trauma center. Methods: A before-and-after INF implementation study was conducted in a pediatric ED with a trauma center on children with a confirmed displaced closed fracture on radiographs with reduction and casting performed in the ED. The time of care, time for sufficient analgesia, effectiveness on pain, and tolerance were compared between both analgesics in 3 consecutive phases. Results: 77 children were included: 31 children received oral morphine and 46 INF. The time of care was shorter in the INF group (150 [111 to 193] minutes versus 215 [155 to 240], P = 0.01) as the time for sufficient analgesia (10 [9 to 13] minutes versus 80 [53 to 119], P < 0.001) with a higher pain reduction after a dose of INF (3 [0 to 4] versus 6 [3 to 7], P < 0.001) and less dose requirement (P = 0.002). Although pain scores were similar at arrival in both groups (P = 0.15), the pain was significantly lower before and during the procedure in the INF group and equivalent after the procedure (2 [0 to 4] versus 3 [0 to 5], P = 0.02, 3 [1 to 5] versus 7 [3 to 9], P < 0.001, and 1 [0 to 2] in both groups, P = 0.87, respectively). Keeping pain levels low during the procedure in the INF group allowed the extension to lower limb fracture reductions (P = 0.04). No serious adverse events were reported. Conclusion: INF reduces the time to obtain sufficient analgesia and time of care, with good effectiveness maintained during the procedure in fracture reduction, allowing the extension to lower limb fractures. Thus, this rapid and efficient analgesia facilitates orthopaedic care in the pediatric ED that would otherwise require to be reduced in the operating room under general anesthesia.

Background Nurse-directed pain protocols for intranasal fentanyl administration are not widely implemented in European (EU) pediatric emergency departments (PED). Barriers include perceived safety concerns for intranasal (IN) fentanyl. The aim of this study is to describe our experience with a nurse-directed triage IN fentanyl protocol with a focus on safety in a tertiary EU PED. Methods We conducted a retrospective analysis of patient records of children aged 0–16 years who received nurse-directed IN fentanyl between January 2019 and December 2021 at the PED of the University Children's Hospital of Bern, Switzerland. Extracted data points included demographics, presenting complaint, pain score, IN fentanyl dosage, concomitant pain medication use, and adverse events. Results A total of 314 patients were identified with ages ranging from 9 months to 15 years. The main indication for nurse-directed fentanyl administration was musculoskeletal pain due to trauma (n = 284, 90%). Mild adverse events (vertigo) were reported in two patients (0.6%), without a correlation to concomitant pain medication or protocol violation. The only reported severe adverse event of syncope and hypoxia in a 14-year-old adolescent occurred in a setting where the institutional nurse-directed protocol was violated. Conclusion In accordance with previous studies outside of Europe, our data support the case that when appropriately used, nurse-directed IN fentanyl is a safe potent opioid analgesic for pediatric acute pain management. We strongly encourage the introduction of nurse-directed triage fentanyl protocols Europe-wide in order to provide effective and adequate acute pain management in children.

Background: Given the inadequate control of pain in patients with the trauma that refer to the emergency departments, the rapid onset of action of intranasal administration in pain management, and the avoidance of administering opioid medications, the present study aimed at evaluating the effect of intranasal ketamine versus intranasal fentanyl on pain management in isolated traumatic patients. Materials and Methods: The current study was performed on 125 patients that were divided into the following three groups: control group (n = 41), 1 mg/kg intranasal ketamine group (n = 40), and 1 μg/kg intranasal fentanyl group (n = 44). Then pain scores, heart rate, respiratory rate, blood pressure, and oxygen saturation were recorded at baseline, 5, 10, 15, 30, and 40 min after the intervention. Results: Visual analog scale (VAS) scores of patients in the intranasal ketamine group 5 and 10 min after the intervention were 61.50 ± 20.45 and 55.00 ± 21.96, respectively. The mentioned scores were significantly lower than the VAS scores of patients in the control group with the mean of 72.44 ± 22.11 and 66.59 ± 24.25 and the VAS scores of patients in the intranasal fentanyl group with the mean of 71.59 ± 22.09 and 65.00 ± 22.87 at 5 and 10 min after the intervention, respectively (P < 0.05). Conclusion: Given the onset of action in < 10 min, intranasal ketamine can be proposed as an appropriate analgesic medication in pain reduction of patients with isolated limb injuries. Moreover, the incidence rate and severity of adverse effects were insignificantly higher in the intranasal ketamine group as compared with the intranasal fentanyl group.

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Abstract Objectives Intranasal (IN) medications offer a safe non-invasive way to rapidly deliver drugs in situations where intravenous (IV) access and intramuscular (IM) administration is challenging or not feasible. In the prehospital setting, this can be an essential alternative in time critical situations including trauma management, seizures, and agitated patients. However, there is a paucity of evidence summarizing its efficacy in this environment. This systematic review aims to assess the current evidence supporting the use of IN medicine (midazolam, ketamine, fentanyl, morphine, glucagon, and naloxone) in the prehospital setting alone. Methods A systematic literature search (PROSPERO CRD42023440713) of PubMed, Web of Science, OVID Medline, “Cochrane Central Register of Controlled Trials,” Cochrane reviews and Embase was performed from inception to June 2023 to identify studies where IN medications were administered to patients in the prehospital setting. All randomized controlled trials, observational cohort studies, case series, and case reports were included. Papers not written in English, review articles, abstracts, and non-published data (including letters to the editor) were excluded. The methodological quality of the included studies was interpreted using the Cochrane risk of bias tool and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. No funding was received. Results From 4818 studies, 39 were included (seven for midazolam, five for ketamine, twelve for fentanyl, one for diamorphine, two for glucagon, and twelve for naloxone). A total of 24,097 patients were treated with IN medications across all the studies. There were five moderate quality, four low quality, and thirty very low quality studies. The potential efficacy of IN fentanyl and ketamine was demonstrated consistently throughout the studies with less clear evidence for midazolam, morphine, glucagon, and naloxone. This review was severely limited by the study quality, with most studies demonstrating “high concerns” for bias. Conclusions Prehospital IN medication administration has wide-ranging potential, particularly for administering analgesia. There are likely to be certain populations, for example, pediatrics, that will benefit the most, although conclusions are limited by the quality of evidence currently available. We encourage additional research in this area, particularly with robust prospective double-blind RCTs.

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Abstract Background Pain associated with pediatric trauma is often under-assessed and under-treated in the out-of-hospital setting. Administering an opioid such as fentanyl via the intranasal route is a safe and efficacious alternative to traditional routes of analgesic delivery and could potentially improve pain management in pediatric trauma patients. Objective The study sought to examine the effect of introducing the mucosal atomization device (MAD) on analgesia administration as an alternative to intravenous fentanyl delivery in pediatric trauma patients. The hypothesis for the study is that the introduction of the MAD would increase the administration of fentanyl in pediatric trauma patients. Methods The research utilized a 2-group design (pre-MAD and post-MAD) to study 946 pediatric trauma patients (age <16) transported by a large, urban EMS agency to one of eight hospitals in Marion County, which is located in Indianapolis Indiana. Two emergency medicine physicians independently determined whether the patient met criteria for pain medication receipt and a third reviewer resolved any disagreements. A comparison of the rates of fentanyl administration in both groups was then conducted. Results There was no statistically significant difference in the rate of fentanyl administration between the pre-MAD (30.4%) and post-MAD groups (37.8%) (P = .238). A subgroup analysis showed that age and mechanism of injury were stronger predictors of fentanyl administration. Conclusion Contrary to the hypothesis, the addition of the MAD device did not increase fentanyl administration rates in pediatric trauma patients. Future research is needed to address the barriers to analgesia administration in pediatric trauma patients. O'DonnellDP, SchaferLC, StevensAC, WeinsteinE, MiramontiCM, KozakMA. Effect of introducing the mucosal atomization device for fentanyl use in out-of-hospital pediatric trauma patients. Prehosp Disaster Med. 2013;28(4):1-3.

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Trauma theatre time is valuable and previous studies reported cost of £24.77/minute. BSUH Children’s emergency department (CED) guidelines were implemented in December 2016, allowing reduction of forearm and distal radius (DR) fractures in CED using 70% nitrous (N2O) sedation. Due to COVID-19 pandemic and the risks associated with aerosol generating procedures as well as staffing levels, CED shifted to using 50%N2O with or without intranasal fentanyl. Relevant fractures presenting to CED from Feb-Dec 2020 were identified and compared to previous years. Demographics, treatment modality, timings, and outcomes were reviewed for 275 patients. In 2017-2018, 56% were manipulated in CED under 70%N2O (compared to only 3% in 2016). The main barrier identified was shortage of doctors trained in sedation to supervise use of 70%N20. In 2020, 101 patients were suitable for manipulation in CED. 64 had DR fractures, 37 midshaft fractures, 65 were male. Mean age: 10 years. 92 patients (91%) were manipulated in CED/fracture clinic. One was under 70%N2O; the rest used 50%N2O with or without intranasal fentanyl. 8 (9%) had manipulation under GA. Of those manipulated in CED, 3 were re-manipulated in clinic for cast problems. A typical MUA takes 30minutes indicating a saving of £743 per case; therefore, £68,356 over the study period. Paediatric upper limb fracture manipulation in CED under N2O is effective and provides significant cost savings. Due to changes related to COVID-19 pandemic, considerably more patients in 2020 were safely treated in CED/clinic. Using 50%N2O improves uptake due to lower staffing requirements.

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BACKGROUND Pain relief is a priority for patients with hip fractures who present to Emergency Departments (EDs). Intranasal fentanyl (INF) is an ideal option for nurse initiated analgesia as it does not require intravenous access and can expedite care prior to examination by a physician. LOCAL PROBLEM Pain relief in patients with hip fractures is delayed during episodes of ED crowding. METHODS A retrospective medical record review was conducted following introduction of an INF guideline in an adult ED in 2018. Patients were included over a 4-month period during which the guideline was introduced. Historical and concurrent control groups receiving usual care were compared to patients receiving INF. INTERVENTIONS This quality improvement initiative investigated whether an INF analgesia at triage guideline would decrease time to analgesic administration in adults with hip fracture in ED. RESULTS This study included 112 patients diagnosed with fractured hips of which 16 patients received INF. Background characteristics were similar between groups. Mean time to analgesic administration (53 v 110 minutes), time to x-ray (46 v 75 minutes), and ED length of stay (234 v 298 minutes) were significantly decreased in the intervention group. Inadequate documentation was a limiting factor in determining improved efficacy of analgesia. CONCLUSION Use of triage-initiated INF significantly decreased time to analgesic administration, time to imaging and overall length of stay in ED.

This systematic review examined the efficacy and safety of intranasal fentanyl (INF) for acute pain treatment in children, adults, and the elderly in prehospital emergency services (PHES) and emergency departments (ED). ClinicalTrials.gov, LILACS, PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane databases were consulted until 31 December 2022. A total of 23 studies were included: 18 in children (1 PHES, 17 ED), 5 in adults (1 PHES, 4 ED) and 1 in older people (1 PHES subgroup analysis). In children, INF was effective in both settings and as effective as the comparator drugs, with no differences in adverse events (AEs); one randomised controlled trial (RCT) showed that INF was more effective than the comparator drugs. In adults, one study demonstrated the efficacy of INF in the PHES setting, one study demonstrated the efficacy of INF in the ED setting, two RCTs showed INF to be less effective than the comparator drugs and one RCT showed INF to be as effective as the comparator, with no difference in AEs reported. In older people, one study showed effective pain relief and no AEs. In summary, INF appears to be effective and safe in children and adults in PHES and ED. More high-quality studies are needed, especially in PHES and older people.

BackgroundOpioid analgesics are used in most trauma systems, and only a few studies report on the use of ketamine for prehospital analgesia. In a low-cost rural trauma system in Iraq paramedics have been using prehospital ketamine analgesia for ten years. This study aims to evaluate the effects of prehospital analgesia on physiologic trauma severity indicators and compare the effect of ketamine and pentazocine on those indicators.MethodsThe investigation was conducted as a retrospective cohort study with parallel group design. Three subsamples of trauma patients were compared: no analgesia (n = 275), pentazocine analgesia (n = 888), and ketamine analgesia (n = 713). Physiologic severity scores were calculated based on rated values for respiratory rate, blood pressure, and consciousness. The associations between outcomes and explanatory variables were assessed using a generalized linear model.ResultsParamedic administration of analgesia was associated with a better physiologic severity score (PSS) outcome (p = 0.01). In the two subsamples receiving analgesia significantly better outcomes were observed for respiration (p < 0.0001) and systolic blood pressure (p < 0.0001). In patients with Injury Severity Score >8 ketamine was associated with a significantly better effect on the systolic blood pressure compared to opioid analgesia (p = 0.03).ConclusionPrehospital analgesia for trauma victims improves physiologic severity indicators in a low-resource trauma system. Compared to pentazocine, ketamine was associated with improved blood pressure for patients with serious injuries. In a low-resource setting, ketamine seems to be a good choice for prehospital analgesia in trauma patients.

Traumatic chest pain, commonly resulting from rib fractures and blunt thoracic trauma, poses a significant analgesic challenge. Ketorolac (a nonsteroidal anti-inflammatory drug) and ketamine (an N-methyl-D-aspartate receptor antagonist) are widely used as opioid-sparing alternatives. This narrative review aimed to synthesize and critically appraise the literature comparing ketorolac and ketamine for pain management in traumatic chest injuries, focusing on efficacy, safety, and clinical applicability. Evidence suggests that ketamine provides faster and superior short-term analgesia, particularly among patients requiring chest tube insertion. At the same time, ketorolac is associated with reduced opioid consumption and lower pulmonary complication rates in rib fracture cohorts. Most findings were derived from indirect comparisons, with only one direct head-to-head randomized controlled trial (RCT) available. Both agents demonstrate favorable safety profiles, though ketamine may cause transient psychedelic effects, and ketorolac may cause bleeding or renal risks in high-risk populations. Given the limited direct comparative data, clinicians may consider ketamine for rapid analgesia and ketorolac for opioid-sparing benefits, tailoring choice to patient-specific factors. Future research should include well-designed RCTs comparing combination versus monotherapy, optimal dosing strategies, and long-term outcomes. Due to the paucity of direct comparative trials, conclusions rely primarily on indirect evidence and a single head-to-head study.

Background and Aims: Acute trauma pain often remains inadequately treated despite opioid therapy. Low-dose ketamine has emerged as a promising adjunct analgesic that may enhance morphine effectiveness while reducing opioid requirements. This systematic review assessed the efficacy and safety of morphine combined with low-dose ketamine versus morphine alone for acute trauma analgesia. Material and Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, comprehensive searches were conducted across six databases (2006–2024) for studies comparing morphine–ketamine combination versus morphine monotherapy in acute trauma patients. Six eligible randomized controlled trials (RCTs) (n = 708) were included. Meta-analysis was performed using RevMan 5.4 software with random-effects modeling. Results: Six RCTs involving 708 patients from emergency departments and prehospital settings were analyzed. Morphine–ketamine combination demonstrated superior analgesic efficacy with significantly lower final pain scores (mean difference (MD): –0.26; 95% confidence interval (CI): –0.40 to –0.12; P = 0.0003). Subgroup analysis by ketamine dose indicated the most pronounced and statistically significant pain reduction at 0.3 mg/kg (MD: –0.30; 95% CI: –0.48 to –0.12; P = 0.001), while lower doses showed similar trends. Significant pain reduction occurred at 30 min after sensitivity analysis (MD: −0.64, P < 0.00001) and sustained through 60 min (MD: −0.32, P < 0.0001). The combination reduced total morphine consumption by 2.93 mg (P = 0.07). Overall, adverse events increased (odds ratio: 2.37, P = 0.05), but specific events—nausea, vomiting, and hallucinations—showed no significant differences between groups. No serious adverse events occurred. Conclusion: Low-dose ketamine as a morphine adjunct improves acute trauma pain control, shows a trend toward reduced opioid requirements, and maintains an acceptable safety profile, supporting its clinical implementation in emergency settings.

BACKGROUND While opioids are frequently used in the emergency department (ED) for pain control of hip fractures, they are associated with poor side effects. The pericapsular nerve group (PENG) block has recently emerged as an opioid-sparing peripheral nerve block for patients with hip fractures. OBJECTIVES The primary objective was to determine whether there is a reduction in morphine milligram equivalents (MME) administered to patients with hip fractures who receive a PENG block in the ED as compared to those who only receive opioids. Secondary outcomes included hospital length of stay and discharge disposition. METHODS A retrospective study of patients with isolated hip fractures was performed at a level 1 urban trauma center. Thirty-six patients received a PENG block and 251 patients did not. Patients who received a PENG block were propensity-score matched against those who received opioids. The primary outcome was subsequent cumulative opioid administration. RESULTS Patients who received a PENG block had a statistically significant reduction in opioid administration. At 6 hours of follow-up, these patients had a reduction in MME by -0.14 MME/kg (95% CI: -0.20, -0.08), and at 18 hours of follow-up, this reduction was -0.14 MME/kg (95% CI: -0.23, -0.04). Secondary outcomes demonstrated comparable effects on length of stay and discharge disposition. CONCLUSION Emergency physician-performed PENG blocks are an effective opioid-sparing analgesic strategy for isolated hip fractures. Larger prospective studies are needed to evaluate this effect estimate and assess mortality outcomes.

Objective: To compare the effect of ketamine, lidocaine, acetaminophen, and dexmedetomidine combined with morphine patient-controlled analgesia for opium addicts after tibial fracture surgery. Methods: This double-blind clinical trial included opium-addicted patients undergoing tibia fracture surgery. Patients were recruited and randomized to four different groups including the ketamine group, the lidocaine group, the acetaminophen group, and the dexmedetomidine group. The hemodynamic parameters such as heart rate (HR), mean arterial pressure, and arterial SaO2, alongside visual analog scale pain scores, sedation assessed by Ramsay score, nausea and vomiting, and opioid use were recorded and compared among the four groups. Results: This study included 140 patients, aged 37 (32, 41) years, with 92 males and 48 females, and each group had 35 patients. Dexmedetomidine-sedated subjects had the lowest blood pressure from 1 to 24 h after surgery, decreased HR at 12 and 24 h after surgery, and more satisfactory sedation (P<0.05). Notwithstanding no significant difference was noted in the pain scores, or nausea and vomiting among the groups (P>0.05). Conclusions: Dexmedetomidine has a better sedation effect compared to ketamine, lidocaine, and acetaminophen for pain control, but the final choice hinges on the patients’ physical condition and the anesthesiologist′s preference. Clinical registarion: It is registered in Iranian Registry Clinical Trial by code IRCT20141209020258N146.

Femur fracture commonly occurs following trauma in elderly patients and central neuraxial block especially spinal anesthesia is more preferred for providing anesthesia for such cases. Proper positioning during spinal anesthesia is a must for a successful procedure, but extreme pain and limb immobility are obstacles for an ideal position for this procedure. Different methods like intravenous fentanyl, ketamine, femoral nerve block or fascia iliaca block have been used to control the pain pre-operatively and improve these patients' positioning. To investigate the effect of Ultrasound guided FNB using 0.25% bupivacaine versus IV analgesic ketamine dose (0.25 mg/kg) in pain control for positioning before spinal anesthesia in patients undergoing surgery for fractured femur. In addition to recording postoperative analgesic effect, postoperative opioid consumption and rate of complications The study was conducted on 60 randomly chosen patients in Ain Shams University Hospitals after approval of the medical ethical committee Results of the study revealed that FNB analgesia was more effective than IV analgesic dose of ketamine for pain control during positioning. The first call for rescue analgesia (morphine), total morphine consumption and postoperative pain scores indicated that the superiority of the FNB technique with opioid sparing effect and lesser complications. Unlike preoperative intravenous ketamine analgesia, preoperative FNB provided better pain control during positioning for spinal blockade in fractured femur patients. Furthermore, FNB was associated with less adverse effects, better postoperative analgesia and less postoperative opioid consumption.

Background Studies have found that pre-hospital and emergency department (ED) analgesia for children is sub-optimal. In the pre-hospital setting, barriers include limited parenteral routes, education or clinical experience and practice legislation restricting the use of opioids by paramedics. Ketamine is safe and effective with multiple administration routes. It is not bound by the controlled drugs limitations in the pre-hospital setting, and is familiar to pre-hospital and ED practitioners. Methods Questionnaires were sent to all UK Ambulance Service Medical Directors and Paediatric Major Trauma Centres to establish current use of parenteral analgesics, and acceptability of alternatives in pre-hospital care such as ketamine. Descriptive analysis was undertaken. Results Intranasal opiates were the first line parenteral analgesics in injured children in all EDs. Frequent shortages of IN diamorphine resulted in more variability of second line choices, with 40% opting for another opioid. 96% of EDs would support the use of ketamine by pre-hospital clinicians, although concerns regarding inappropriate (IV) use and use by technician crews were raised. Most ED clinicians were unaware of the limited analgesic choices available to paramedics, with many suggesting alternative opiates as well as ketamine. All ambulance service directors recognised the need for alternative analgesics being made available. Without legislative changes, inhaled/IN agents or oral opiates were the only current options. All services were supportive of research to explore the use of ketamine by paramedics for injured children. Conclusions There is support for the addition of IN ketamine into paramedics’ repertoire of analgesics and recognition of potential benefit. However, there is a lack of experience and evidence around its use, thus warranting research to consider the impact on analgesic timeliness, adequacy and effectiveness. An analgesia ‘system of care’ which integrates pre- and in-hospital practice would be facilitated by the use of medicines effective in managing pain and familiar to practitioners in both settings.

BACKGROUND Effective prehospital analgesia is vital in trauma care. Although opioids are first line, they carry risks of adverse events. Ketamine has emerged as a promising alternative, offering potent analgesia, dissociation, and a favorable hemodynamic profile suited to resource-limited, time-sensitive prehospital care. OBJECTIVE The objective of this systematic review and meta-analysis was to evaluate the analgesic effectiveness and physiologic effects of ketamine compared with opioid-based analgesia in adult patients with traumatic injuries treated in the prehospital setting. METHODS CINHAL Plus (EBSCO), OVID, and Cochrane Central were searched (2013-2024) using MESH terms such as ``ketamine,'' ``prehospital,'' and ``trauma.'' Included studies involved adults with traumatic injuries treated by prehospital clinicians with ketamine. Comparators included opioid monotherapy and ketamine-opioid combinations. Primary outcomes were pain scores, hemodynamic parameters, and adverse events. Risk of bias was assessed using established tools for randomized and nonrandomized studies, and certainty of evidence was evaluated using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations). Meta-analyses were conducted using a quality-effects model incorporating study-level risk of bias. RESULTS Eighteen studies met inclusion criteria; three were suitable for meta-analysis comparison of ketamine and opioid monotherapy. Ketamine was not associated with a significant difference in pain reduction compared with opioids (weighted mean difference [WMD] 0.00; 95% confidence interval [CI] -0.77-0.78). Heart rate increased modestly with ketamine (WMD 3.19 beats/min, 95% CI 1.48-4.90), whereas systolic blood pressure showed no difference as compared with opioids (WMD 1.53 mm Hg, 95% CI -2.68-5.75). No difference in respiratory rate was observed (WMD -0.07 breaths/min, 95% CI -0.84-0.70). Adverse events were infrequent and were primarily mild, with emergence reactions most common. CONCLUSIONS Ketamine provides analgesia consistent with similar effectiveness to opioids in prehospital trauma care, with comparable physiological effects and low reported rates of serious adverse events.

Optimal pain management is challenging in Tactical Combat Casualty Care (TCCC), particularly in remote and austere settings. In these situations, appropriate treatment for prehospital analgesia can be limited or delayed due to the lack of intravenous access. Several guidelines suggest to implement intranasal (IN) analgesia in French Armed Forces for forward combat casualty care (Sauvetage au Combat), similar to the US TCCC. Four medical teams from the French Medical Military Service were deployed to the Middle East and Sahel from August 2017 to March 2019 and used IN ketamine for analgesia in 76 trauma patients, out of a total of 259 treated casualties. IN administration of ketamine 50mg appeared to be safe and effective, alone or in addition to other opioid analgesics. It also had minimal side effects and led to a reduction in the doses of ketamine and morphine used by the intravenous (IV) route. The French Military Medical Service supports current developments for personal devices delivering individual doses of IN ketamine. However, further studies are needed to analyze its efficacy and safety in combat zones.

Combat surgical trauma of the extremities is accompanied by a pronounced pain syndrome, which requires effective control at all stages of medical evacuation. Regional anesthesia is considered a promising component of multimodal analgesia. The purpose of the study was to evaluate the effectiveness of different perioperative analgesia regimens in wounded with combat surgical trauma of the extremities. The prospective study included: patients of Group 1 (n=50) received general anesthesia with systemic analgesia, patients of Group 2 (n=50) – combined anesthesia with regional blocks. Pain intensity was assessed at four stages. Upon admission, pain level was 7 points (6; 8) without intergroup differences (p=0.57). After surgery, pain was significantly lower in Group 2 – 1 point (1; 2) vs 3 points (3; 4) (p<0.05). At the evacuation stage, values were: 1 point (1; 2) and 3 points (2; 3), respectively (p<0.05). After transportation, the difference persisted: 1 point (1; 2) vs 5 points (4; 6) (p<0.05). Intraoperative fentanyl consumption was lower (0 vs 0.3 mg), as well as propofol (3.3±0.7 vs 8.5±1.2 mg/kg/h). Awakening time was 0 min vs 10 min. Opioids in the postoperative period were used in 6% of patients in Group 2 vs 74% of patients in Group 1, and during transportation – in 6% vs 24%, respectively. Regional analgesic blocks provide more effective pain control, reduce the need for opioids, and improve the course of the postoperative period in wounded with combat surgical trauma of the extremities.

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Background Pain related to trauma is often severe and undergoes undertreated in many patients. Peripheral nerve blocks provide analgesia, which is site-specific and devoid of any systemic adverse effects. Regional anesthesia may also confer several other advantages including decreased length of stay in the emergency department and improved comfort and safety for emergency procedures compared to conventional analgesia. This study aims to evaluate the feasibility of the application of nerve blocks in upper and lower extremity trauma patients presenting to the Emergency Department of a tertiary care hospital. Methodology We conducted a prospective observational study in the Department of Emergency Medicine (EM) at Dr. D. Y. Patil Medical College, Hospital & Research Centre, Pimpri, Pune between 2023 and 2024. As a part of this research proposal, we intended to study the application of nerve blocks in upper and lower extremity trauma among patients presenting with upper and lower extremity trauma to the ED during the study period. After institutional Ethics Committee approval and informed written consent, 95 patients aged above 18 years presenting with upper and lower extremity trauma within 12 hours were selected. Patients under 18 years old, those with a history of coagulopathies, patients with open fractures, and pregnant patients were excluded from the study. Results The study comprised 95 participants, with diverse age groups represented. Among them, 26% were under 25 years old, 54% fell between the ages of 26 and 30, and 20% were over 30 years old. Gender distribution showed 64.2% male and 35.8% female participants. In terms of injury nature, the majority experienced injuries from motor vehicle crashes (31.5%) and domestic incidents (22.1%), followed by workplace injuries (15.8%), sports injuries (14.7%), falls from heights (7.4%), and assault (7.4%). The time required for interventions varied, with 41.1% of cases completed in five minutes or less, while in 58.9% of instances, more than five minutes were necessary. Similarly, the time taken for pain relief post-intervention was reported, with 66.3% experiencing relief within five minutes and 33.7% requiring more than five minutes. On initial presentation, the mean VAS score was 8.8 with an SD of 1.1, indicating high levels of pain. Following the block, there was a significant reduction in pain, with the mean VAS score dropping to 1.9 and an SD of 1.2. This change was statistically significant with a p-value of less than 0.001, indicating a substantial improvement in pain levels post-block administration. Regarding the duration of pain relief, a similar pattern emerged, with 77.8% reporting relief lasting three hours or less, and 22.2% experiencing relief for more than three hours. Conclusion In emergency situations, our research showed that peripheral nerve blocks are a very useful tool for treating pain from trauma to the upper and lower extremities. These blocks significantly reduce pain and have a long-lasting effect. Further research with larger, multi-center trials is needed to validate these findings and explore long-term outcomes.

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This methodology constitutes a comprehensive, standardized protocol designed to ensure continuity of analgesia for patients, primarily those with extremity trauma, throughout the entire care pathway, from the moment of first aid in the prehospital setting to completion of treatment in the hospital. The persistent problem of fragmented analgesia, typified by inadequate pain therapy (oligoanalgesia) delivered by emergency medical services (EMS) and the subsequent loss of continuity upon transfer to the emergency department, precipitates pain escalation, a cascade of pathophysiological stress responses, and a heightened risk of complications such as delirium and chronic pain. The objective is to present a systematic, reproducible, integrated methodology that guarantees a seamless transition between care phases. Scientific novelty lies mainly in a developed joint diagnostic-therapeutic algorithm that includes both prehospital and in-hospital anesthesiological phases. Indications and contraindications, as well as ultrasound-guided methods for performing core blocks (femoral nerve block and fascia iliaca block), are described and interpreted in a systematic way as part of this study. The remaining chapters cover hospital admission, conversion of the single-shot blockade to a catheter-based technique, and the principles of regional anesthesia as part of multimodal analgesia. The key to the book’s coherence is the adoption of a communication/data transfer protocol, IMIST-RA, that the author adapted from standard handover protocols to regional anesthesia-specific features. It can lead to better clinical outcomes, greater patient satisfaction, and a more optimized use of resources.

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The treatment of acute pain with opioid sparing techniques has become a particular interest given the recent epidemic of opioid misuse. While acute pain and regional anesthesia are typically managed by the department of anesthesiology in large academic institutions, smaller community hospitals may have limited options for the treatment of acute pain outside of the perioperative setting. Emergency physicians are uniquely positioned to fill this gap given that US guided nerve blocks are now considered a core skill. In this article we outline a successful implementation of a business proposal for provision of regional anesthesia by emergency physicians as consultants to emergency department and hospitalized patients.

Background: The Fontan procedure is the principal technique used in the surgical palliation of a range of congenital heart defects involving a single functional ventricle. With improvements in surgical technique and medical management, patients with Fontan physiology are surviving longer and a growing number are now presenting for noncardiac surgery in adulthood. The Fontan physiology provides a unique challenge for anaesthesiologists managing their perioperative care. This case report explores this challenge further and emphasises the benefits which regional anaesthesia can provide in the management of these complex patients.

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Background and Objectives: Ultrasound (US)-guided peripheral regional anesthesia (pRA) is gaining increasing importance in emergency medicine as an effective, low-ridsk alternative to general anesthesia (GA), procedural sedation (PS), or opioid therapy. By enabling rapid, direct pain management in the emergency department (ED), pRA can help preserve scarce surgical and anesthetic resources and, in some cases, avoid inpatient admissions. The aim of this study was to analyze the indications, techniques, and clinical impact of pRA in the orthopedic-focused ED of an affiliated hospital. Materials and Methods: All pRA and PS procedures performed over a six-year period were retrospectively reviewed among 35,443 orthopedic-trauma emergency patients. pRA was carried out under US guidance with standardized monitoring. Diagnoses, block techniques, effectiveness, and complications were analyzed descriptively. Results: A total of 1292 patients (3.7%) underwent either pRA (n = 1117; 3.2%) or PS (n = 175; 0.5%). pRA was performed in 22% of cases for interventions such as reductions or extensive wound management. In 78%, pRA was applied for analgesia, for example, in the diagnostic work-up and treatment of non-immediately operable fractures, lumbago, or arthralgia. The most common pRA techniques were brachial plexus blocks (54%) and femoral nerve blocks (25%). Fascial plane blocks (6.1%) and paravertebral blocks (1.5%) were rarely used. PS was performed in 175 of 1292 patients (13%), although pRA would have been feasible in 159 of these cases. No complications of pRA were observed, and GA could routinely be avoided. Conclusions: US-guided pRA proved to be an effective and safe alternative to PS, GA, or systemic analgesia for selected indications, allowing immediate treatment without the need for operative capacities. To ensure safe application, these techniques should be an integral part of the training curriculum for ED personnel.

Regional anesthesia in acute trauma care is gaining popularity due to its benefits, advancements in techniques and equipment, and improved training. Nerve blocks are increasingly performed in trauma settings by various health care providers, including anesthesiologists, emergency medicine and acute care practitioners, and even prehospital providers. Emerging studies support incorporating regional anesthesia into injury treatment protocols. Trauma patients require special considerations to ensure safety, efficacy, and optimal benefit. This article explores current research and future directions for regional anesthesia in trauma care.

Purpose: Despite evidence that regional anesthesia may facilitate earlier discharge and lower outpatient opioid utilization, a multitude of systemic and cultural barriers reduce the utilization of regional anesthesia in the emergency setting. An accessible regional anesthesia team was created to assess Emergency Department (ED) utilization of nerve blocks and their impact on patient pain improvement. Materials and methods: ED providers in a non-trauma hospital had a regional anesthesia team available as a consulting service for five months. Patients were enrolled based on inclusion criteria and at the discretion of the ED attending. Enrolled patients underwent peripheral nerve blocks with one of two anesthesiologists who were fellowship trained in Regional Anesthesiology. Patients were then contacted on post-procedure day 1 and were interviewed regarding their satisfaction with the process and their ultimate post-ED disposition. Results: Participation was limited due to multiple systemic and cultural factors. The majority of patients enrolled participated in the follow-up survey and rated their pain relief as 'Very Good' or 'Excellent' (n=9/14). Nearly all patients (n = 11/14) responded ‘Strongly Agree’ to whether they would use the same type of pain relief method in the future, and most (n=11/14) rated their overall experience with their pain management service as ‘Excellent’ or ‘Very Good’. Conclusion: This pilot study showed that implementation of a regional anesthesia consulting service in the ED was feasible and that the majority of patients were satisfied with the quality of care and the timeframe in which they were provided regional anesthesia for acute pain.

Trauma frequently occurs during pregnancy and occurs 1 in 12 pregnant women affecting maternal mortality, morbidity, and also pregnancy outcome. Hence, it is essential to consider pregnancy in every female trauma patient of reproductive age. Motor vehicle accidents and domestic/intimate partner violence account for most cases of major maternal trauma. Most of the causes mentioned above can lead to facial injuries/head injuries making it challenging for the anesthesia provider. We report a parturient who presented to us with multiple facial injuries with a suspected head injury following a road traffic accident with restricted mouth opening. The anesthesiologist is put in a dilemma to choose between general and regional anesthesia in such full-term parturients where patients present with suspected head injury anticipating increased intracranial pressure and at the same time are difficult airway posted for emergency C-section in a limited resource setting with no difficult airway gadgets. Management of full-term pregnant patients with major trauma presents unique challenges since the presence of a fetus means two patients are potentially at risk, both of whom require evaluation and management. An anesthetist has to evaluate the patient, assess the risks and benefits of both regional and general anesthesia, and plan perioperative care accordingly within a limited time. Management of such presentation needs a team approach of neurosurgeons, obstetricians, anesthesiologists, and pediatricians to have a smooth and safe conduction of delivery and care of the newborn postoperatively. The anesthetist plays an important role as a perioperative physician in such cases by taking adequate preoperative neuroprotective measures, choosing a near-ideal mode of anesthesia by weighing the risk-benefits of general versus regional anesthesia, and giving adequate postoperative monitoring and care.

The risk of complications of anaesthesia is significantly increased in some circumstances specific to emergency patients with pelvic and lower limb injuries. Therefore, in recent years, anaesthesiologists have given preference to regional anaesthesia in operations on pelvic organs and lower extremities.AIM OF THE STUDY. Comparative evaluation of the methods of general and regional anaesthesia in operations for pelvic and lower limb injuries.MATERIAL AND METHODS. The data of 101 patients aged from 21 to 78 years, operated in the early posttraumatic period, were included in the study. In group 1 (27 patients) multicomponent endotracheal anaesthesia was used, patients of group 2 (16 patients) were operated under epidural anaesthesia. Patients of the 3rd group (36 patients) underwent surgical intervention under subarachnoid anaesthesia. Group 4 (22 patients) included patients operated under spinal anaesthesia — bupivacaine combined with morphine hydrochloride in a dose of 0.07–0.08 mg.RESULTS. The most adequate method of postoperative analgesia was the method used in patients of group 4. A single injection of bupivacaine 10–15 mg in combination with morphine (0.08–0.1 mg/kg) provided rapid-onset, adequate, long-lasting (24–72 hours) analgesia without hemodynamic depression. Respiration and SpO2 were adequate, patients were in a light sedation (level II) and a state of emotional calm and comfort.CONCLUSION. Spinal anaesthesia with bupivacaine combined with morphine hydrochloride at a dose of 0.07–0.08 mg is the method of choice of anaesthetic aid in orthopedic trauma surgeries, which provides good analgesia and hemodynamic stability with adequate spontaneous breathing of the patient during surgery.

This clinical case report describes the management of a 36-year-old pregnant female at 36 weeks gestation, who was admitted to King Abdulaziz Medical City following a motor vehicle accident. The patient, with a history of gestational diabetes mellitus, sustained multiple fractures requiring surgical intervention. A combined spinal and supraclavicular block was chosen for anesthesia, with a contingency plan for general anesthesia and emergency cesarean section if needed. The surgical procedures were completed successfully, and the patient was stable postoperatively.

Emergency and trauma surgeries present unique challenges for anesthesiologists due to the acuity of patient conditions and the need for rapid intervention. This review aims to provide insights into the optimal management of anesthesia in emergency and trauma surgery settings. We searched the National Institute of Health PubMed, Scopus, MEDLINE, and Web of Science databases between 2014 and 2024 to synthesize current evidence and best practices for anesthesia management during emergency and trauma surgeries. This literature review examines the evolving role of anesthesia in emergency and trauma surgeries, focusing on key considerations such as patient management, hemodynamic stability, and the choice of anesthetic agents. The review discusses recent advancements in anesthesia techniques, including the use of regional anesthesia and multimodal analgesia, to optimize patient outcomes while minimizing complications. Additionally, it discusses the importance of interdisciplinary collaboration among anesthesiologists, surgeons, and other healthcare professionals in delivering timely and effective care to critically injured patients.

Aim We performed a subgroup analysis of a previously reported randomised, double-blind, placebo-controlled study of low-dose methoxyflurane analgesia for the treatment of acute trauma pain in UK Emergency Departments [STOP!].1,2 Method At triage, patients aged ≥12 years (n=300) with a pain score of 4–7 on the Numeric Rating Scale (NRS) were randomised 1:1 to methoxyflurane (up to 6 mL) or placebo (normal saline). Study medication was self-administered by the patient using a Penthrox® inhaler. Rescue medication (paracetamol/opioids) was available immediately upon request. Adverse events (AEs) were recorded from enrolment until discharge, and at Day 14±2. Analyses of time to first pain relief, time to request for rescue medication and AEs were performed in a subgroup of patients with severe pain (NRS=7) at baseline (n=133). Results Median time to first pain relief was significantly shorter with methoxyflurane than placebo (3 min versus 5 min, hazard ratio: 2.21; 95% CI: 1.45 to 3.37; p=0.0002). The proportion of patients who requested rescue medication was significantly lower in the methoxyflurane group (9.7%) than the placebo group (32.4%), with a significantly longer time to request for rescue medication in the methoxyflurane group (hazard ratio: 0.19; 95% CI: 0.08 to 0.48; p=0.0004). AEs (mostly mild, transient dizziness and headache) were reported by 50.0% of methoxyflurane patients and 42.3% of placebo patients. Conclusion Low-dose methoxyflurane administered via the Penthrox® inhaler provides effective analgesia in adult and adolescent patients presenting with severe acute trauma pain. References . Coffey F. Emerg Med J2014;31:613–8. . Coffey F, et al. Adv Ther2016;33:2012–31. ®: PENTHROX is a registered trademark of MDI Limited. Conflict of interest Frank Coffey was paid travel and subsistence expenses by MDI for one investigator’s meeting. Mark Lomax is an employee of Mundipharma Research Limited. There were no other competing interests. Funding The study was funded by Medical Developments International (MDI) Limited. Karen Mower (Scientific Editorial) provided medical writing services on behalf of Mundipharma Research Limited.

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Aim: Procedural Sedation and Analgesia (PSA) is crucial in pediatric emergency care to minimize discomfort, enhance procedural success, and improve satisfaction for both healthcare providers and caregivers. This study aims to evaluate the characteristics of pediatric patients who received ketamine for PSA in the emergency department (ED) and to assess associated adverse events.Material and Methods: This prospective observational study analyzed collected data from pediatric patients (3 months–18 years) who underwent ketamine-based PSA in the ED between June 21 and September 17, 2021. Data included demographics, nutritional status, ketamine dosing, oxygen support needs, and vital signs (e.g., blood pressure, oxygen saturation, respiratory rate, heart rate, end-tidal CO₂). Sedation levels (Ramsey Scale) and adverse events such as hypoxemia, apnea, hypercarbia, hiccups, hypersalivation, muscle twitching, vomiting, and transient apnea were recorded pre-, intra-, and post-procedure.Results: Sixty pediatric patients (mean age: 3.5 ± 1 years; 46 males, 76.7%) were included. Most (98.3%) were ASA I, with one (1.7%) classified as ASA II. No significant differences were noted in vital signs except for increased systolic and diastolic blood pressure. Adverse events included agitation (16.7%), hiccups (11.7%), muscle twitching (10%), hypersalivation (8.3%), vomiting (3.3%), clonus (1.7%), transient apnea (1.7%), and nystagmus (1.7%). No severe complications occurred.Conclusion: Although adverse events may occur during pediatric PSA with ketamine, serious events are rare. Ketamine demonstrates a favorable safety profile with no serious adverse events, confirming that single-agent PSA is a reliable practice in the pediatric ED when managed with appropriate clinical vigilance.

Scapular fractures, typically resulting from high-energy trauma, cause severe pain that restricts shoulder girdle movement and delays rehabilitation. Adequate analgesia is essential to facilitate physiotherapy and improve recovery, yet optimal techniques remain underutilized in the Emergency Department (ED). Suprascapular nerve block may offer an effective solution to this challenge. We report a series of ten adult patients with traumatic scapular fractures who presented to the ED with severe pain (Defense and Veterans Pain Rating Scale ≥7) and a mean Injury Severity Score (ISS) of 30. All patients underwent ultrasound-guided suprascapular nerve block performed by trained ED physicians using point-of-care ultrasound. Pain scores were recorded at baseline, 30 min, 60 min, and 2 h after the block, and adverse events were monitored for two hours. The mean baseline pain score was 8.9 ± 0.7, which reduced to 2.9 ± 0.9 at 30 min, 1.5 ± 0.97 at 60 min, and 1.1 ± 0.3 at two hours post-procedure (p < 0.001). All ten patients achieved at least a 50 % reduction in pain within 30 min. Complications such as pneumothorax, vascular puncture, or local anesthetic toxicity were not observed. All patients were able to move their shoulders without pain within an hour of the block. Ultrasound-guided suprascapular nerve block is a rapid, safe, and highly effective analgesic intervention for traumatic scapular fractures in the ED. In the future, a randomized controlled trial should be performed to prove the efficacy of the suprascapular nerve block in providing analgesia for traumatic scapular fractures.

BACKGROUND We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications. METHODS We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. RESULTS We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty). CONCLUSION When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.

BACKGROUND Delays in analgesia remain common after traumatic injury, but whether greater injury severity is associated with faster analgesia is not well defined. OBJECTIVES We evaluated the association between Injury Severity Score (ISS) and time to first documented emergency department analgesia. METHODS We conducted a retrospective cohort study of adult trauma registry encounters at a Level I trauma center from May 1, 2022, through April 30, 2025. The primary outcome was time from emergency department arrival to first documented qualifying analgesic administration. Patients without documented analgesia were censored at emergency department departure. Cox models evaluated ISS continuously and by categories: 1 to 8, 9 to 15, 16 to 24, and 25 or greater. Secondary outcomes were analgesia within 30 and 60 minutes. RESULTS Among 6,095 included encounters, the primary ISS analytic cohort included 5,093. Overall, 3,072 patients received documented analgesia (60.3%). Median time to documented analgesia was 104.5 minutes (IQR 56.0-206.1). Analgesia was documented within 30 minutes in 220 patients (4.3%) and within 60 minutes in 836 patients (16.4%). Higher ISS was associated with shorter time to documented analgesia (hazard ratio 1.028 per ISS point; 95% CI 1.023 to Y1.034). Categorical and sensitivity analyses showed a nonlinear association: ISS 9-15 and ISS 16-24 were associated with faster documented analgesia, whereas ISS 25 or greater had the lowest rates of early documented analgesia. CONCLUSION Injury severity was associated with documented analgesic timing in a nonlinear pattern, with the lowest rates of early documented analgesia among the most severely injured patients.

Background Paediatric Procedural Sedation and/ or Analgesia (PPSA) is the recommended standard of practice for children undergoing painful and distressing procedures outside the operating room; however, global practice may vary. In Sub-Saharan Africa, data on the practice of PPSA is lacking. This study aimed to determine the current practice and outcomes of PPSA in the Emergency unit of Mulago National Referral Hospital to inform future standardisation of care. Methods We conducted a descriptive study from 1st October to 31st December 2023 in the surgical section of the emergency unit of Mulago National Referral Hospital. Data was collected using specifically designed and pretested observational checklists, documenting demographics, pre-procedure assessment and preparation, intra-procedural and post-procedural care, average sedation scores attained, pain control and adverse events observed. Data was coded using EPI-Data and analysed to describe PPSA practice and outcomes. Results We recruited 183 children undergoing procedures at the surgical section of the emergency unit. Majority were male, 104(56.8 %), and the median age (IQR) was 8 (4–12)years. Most procedures performed were orthopaedic, 149(81.4 %). Only 15(8.2 %) children got both sedation and analgesia, 4(2.2 %) got sedation only while 164(89.6 %) got analgesia only. Propofol was the most used sedative, while lignocaine with paracetamol was the most used analgesia. Most children, 92(50.3 %), had pain scores ≥8, and adverse events occurred in 6(3.3 %), all of whom belonged to the sedation and analgesia group. Anaesthetic officers were the primary providers in 75 % of the sedation-only cases and 46.7 % of the sedation and analgesia group. Conclusion PPSA practice in this Emergency setting deviates from recommended standards with limited monitoring and inadequate pain control. The clustering of adverse events among children receiving both sedation and analgesia underscores safety risks. Safer sedative choices, clear provider roles, local guidelines, and targeted training are needed to improve the safety and quality of PPSA.