Application of analgesics in emergency services in Germany: a survey of the medical directors.
Administration and dosage
Analgesia
Medical directors
Prehospital emergency care
Journal
BMC emergency medicine
ISSN: 1471-227X
Titre abrégé: BMC Emerg Med
Pays: England
ID NLM: 100968543
Informations de publication
Date de publication:
14 09 2023
14 09 2023
Historique:
received:
03
06
2023
accepted:
31
08
2023
medline:
18
9
2023
pubmed:
15
9
2023
entrez:
14
9
2023
Statut:
epublish
Résumé
BACKGROUND: Treatment of acute pain is an essential element of pre-hospital care for injured and critically ill patients. Clinical studies indicate the need for improvement in the prehospital analgesia. The aim of this study is to assess the current situation in out of hospital pain management in Germany regarding the substances, indications, dosage and the delegation of the use of analgesics to emergency medical service (EMS) staff. A standardized survey of the medical directors of the emergency services (MDES) in Germany was carried out using an online questionnaire. The anonymous results were evaluated using the statistical software SPSS (Chi-squared test, Mann-Whitney-U test). Seventy-seven MDES responsible for 989 rescue stations and 397 EMS- physician bases in 15 federal states took part in this survey. Morphine (98.7%), Fentanyl (85.7%), Piritramide (61%), Sufentanil (18.2%) and Nalbuphine (14,3%) are provided as opioid analgesics. The non-opioid analgesics (NOA) including Ketamine/Esketamine (98,7%), Metamizole (88.3%), Paracetamol (66,2%), Ibuprofen (24,7%) and COX-2-inhibitors (7,8%) are most commonly available. The antispasmodic Butylscopolamine is available (81,8%) to most rescue stations. Fentanyl is the most commonly provided opioid analgesic for treatment of a traumatic pain (70.1%) and back pain (46.8%), Morphine for visceral colic-like (33.8%) and non-colic pain (53.2%). In cases of acute coronary syndrome is Morphine (85.7%) the leading analgesic substance. Among the non-opioid analgesics is Ketamine/Esketamine (90.9%) most frequently provided to treat traumatic pain, Metamizole for visceral colic-like (70.1%) and non-colic (68.6%) as well as back pain (41.6%). Butylscopolamine is the second most frequently provided medication after Metamizole for "visceral colic-like pain" (55.8%). EMS staff (with or without a request for presence of the EMS physician on site) are permitted to use the following: Morphine (16.9%), Piritramide (13.0%) and Nalbuphine (10.4%), and of NOAs for (Es)Ketamine (74.1%), Paracetamol (53.3%) and Metamizole (35.1%). The dosages of the most important and commonly provided analgesic substances permitted to independent treatment by the paramedics are often below the recommended range for adults (RDE). The majority of medical directors (78.4%) of the emergency services consider the independent application of analgesics by paramedics sensible. The reason for the relatively rare authorization of opioids for use by paramedics is mainly due to legal (in)certainty (53.2%). Effective analgesics are available for EMS staff in Germany, the approach to improvement lies in the area of application. For this purpose, the adaptations of the legal framework as well as the creation of a guideline for prehospital analgesia are useful.
Identifiants
pubmed: 37710177
doi: 10.1186/s12873-023-00878-8
pii: 10.1186/s12873-023-00878-8
pmc: PMC10500886
doi:
Substances chimiques
Esketamine
50LFG02TXD
Ketamine
690G0D6V8H
Analgesics, Non-Narcotic
0
Dipyrone
6429L0L52Y
Acetaminophen
362O9ITL9D
Nalbuphine
L2T84IQI2K
Pirinitramide
4RP92LYZ2F
Butylscopolammonium Bromide
2Z3E1OF81V
Analgesics
0
Analgesics, Opioid
0
Fentanyl
UF599785JZ
Morphine Derivatives
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
104Informations de copyright
© 2023. BioMed Central Ltd., part of Springer Nature.
Références
Studnek JR, et al. The association between patients’ perception of their overall quality of care and their perception of pain management in the prehospital setting. Prehosp Emerg Care. 2013;17(3):386–91.
doi: 10.3109/10903127.2013.764948
pubmed: 23611142
Galinski M, et al. Prevalence and management of acute pain in prehospital emergency medicine. Prehosp Emerg Care. 2010;14(3):334–9.
doi: 10.3109/10903121003760218
pubmed: 20507221
Friesgaard KD, et al. Acute pain in the prehospital setting: a register-based study of 41.241 patients. Scand J Trauma Resusc Emerg Med. 2018;26(1):53.
doi: 10.1186/s13049-018-0521-2
pubmed: 29970130
pmcid: 6029421
Das Notfallsanitätergesetz vom 22. Mai 2013 (BGBl. I S. 1348), zuletzt geändert durch Beschlussempfehlung und Bericht des Ausschusses für Gesundheit (14. Ausschuss) v. 21.6.2023 (BGBl. I S. 1174) https://www.gesetze-im-internet.de/btmg_1981/index.html#BJNR106810981BJNE000916116 and https://dserver.bundestag.de/btd/20/073/2007397.pdf .
Gesetz über den Verkehr mit Betäubungsmitteln (Betäubungsmittelgesetz - BtMG). "Betäubungsmittelgesetz in der Fassung der Bekanntmachung vom 1. März 1994 (BGBl. I S. 358), zuletzt durch Beschlussempfehlung und Bericht des Ausschusses für Gesundheit (14. Ausschuss) v. 21.6.2023 geändert. Available from: https://www.gesetze-im-internet.de/btmg_1981/index.html#BJNR106810981BJNE000916116 and https://dserver.bundestag.de/btd/20/073/2007397.pdf .
Scharonow M, et al. Project for the introduction of prehospital analgesia with fentanyl and morphine administered by specially trained paramedics in a rural service area in Germany. J Pain Res. 2017;10:2595–9.
doi: 10.2147/JPR.S151077
pubmed: 29158691
pmcid: 5683795
Friesgaard KD, et al. Efficacy and safety of intravenous fentanyl administered by ambulance personnel. Acta Anaesthesiol Scand. 2016;60(4):537–43.
doi: 10.1111/aas.12662
pubmed: 26612100
Schempf B, Casu S, Haske D. Prehospital analgesia by emergency physicians and paramedics: comparison of effectiveness. Anaesthesist. 2017;66(5):325–32.
doi: 10.1007/s00101-017-0288-2
pubmed: 28258297
Dissmann PD, et al. A review of the burden of trauma pain in emergency settings in Europe. Pain Ther. 2018;7(2):179–92.
doi: 10.1007/s40122-018-0101-1
pubmed: 29860585
pmcid: 6251834
Jabourian A, et al. Evaluation of Safety and Efficacy of Prehospital Paramedic Administration of Sub-Dissociative Dose of Ketamine in the Treatment of Trauma-Related Pain in Adult Civilian Population. Cureus. 2020;12(8): e9567.
pubmed: 32782893
pmcid: 7411289
Kiavialaitis GE, et al. Clinical practice of pre-hospital analgesia: an observational study of 20,978 missions in Switzerland. Am J Emerg Med. 2020;38(11):2318–23.
doi: 10.1016/j.ajem.2019.10.033
pubmed: 31785972
Berben SA, et al. Prevalence and relief of pain in trauma patients in emergency medical services. Clin J Pain. 2011;27(7):587–92.
doi: 10.1097/AJP.0b013e3182169036
pubmed: 21505324
Oberholzer N, et al. Factors influencing quality of pain management in a physician staffed helicopter emergency medical service. Anesth Analg. 2017;125(1):200–9.
doi: 10.1213/ANE.0000000000002016
pubmed: 28489643
Helm M, et al. Oligoanalgesia in patients with an initial Glasgow Coma Scale Score >/=8 in a physician-staffed helicopter emergency medical service: a multicentric secondary data analysis of >100,000 out-of-hospital emergency missions. Anesth Analg. 2020;130(1):176–86.
doi: 10.1213/ANE.0000000000004334
pubmed: 31335406
Hebsgaard S, Mannering A, Zwisler ST. Assessment of acute pain in trauma-A retrospective prehospital evaluation. J Opioid Manag. 2016;12(5):347–53.
doi: 10.5055/jom.2016.0351
pubmed: 27844474
Hollis GJ, et al. Prehospital ketamine use by paramedics in the Australian Capital Territory: A 12 month retrospective analysis. Emerg Med Australas. 2017;29(1):89–95.
doi: 10.1111/1742-6723.12685
pubmed: 27699989
Brokmann JC, et al. Analgesia by telemedically supported paramedics compared with physician-administered analgesia: a prospective, interventional, multicentre trial. Eur J Pain. 2016;20(7):1176–84.
doi: 10.1002/ejp.843
pubmed: 26914284
Lenssen N, et al. Quality of analgesia in physician-operated telemedical prehospital emergency care is comparable to physician-based prehospital care - a retrospective longitudinal study. Sci Rep. 2017;7(1):1536.
doi: 10.1038/s41598-017-01437-5
pubmed: 28484212
pmcid: 5431537
Friesgaard KD, et al. Prehospital intravenous fentanyl administered by ambulance personnel: a cluster-randomised comparison of two treatment protocols. Scand J Trauma Resusc Emerg Med. 2019;27(1):11.
doi: 10.1186/s13049-019-0588-4
pubmed: 30732618
pmcid: 6367789
Schaller SJ, et al. Differences in pain treatment between surgeons and anaesthesiologists in a physician staffed prehospital emergency medical service: a retrospective cohort analysis. BMC Anesthesiol. 2019;19(1):18.
doi: 10.1186/s12871-019-0683-0
pubmed: 30704401
pmcid: 6357417
Sobieraj DM, et al. Comparative effectiveness of analgesics to reduce acute pain in the prehospital setting. Prehosp Emerg Care. 2020;24(2):163–74.
doi: 10.1080/10903127.2019.1657213
pubmed: 31476930
Shackelford SA, et al. Prehospital pain medication use by U.S. Forces in Afghanistan. Mil Med. 2015;180(3):304–9.
doi: 10.7205/MILMED-D-14-00257
pubmed: 25735021
Haske D, et al. Analgesia in patients with trauma in emergency medicine. Dtsch Arztebl Int. 2017;114(46):785–92.
pubmed: 29229039
pmcid: 5730701
McCarthy CP, et al. The on- and off-target effects of morphine in acute coronary syndrome: a narrative review. Am Heart J. 2016;176:114–21.
doi: 10.1016/j.ahj.2016.04.004
pubmed: 27264228
Ibrahim K, et al. Fentanyl delays the platelet inhibition effects of oral ticagrelor: full report of the PACIFY randomized clinical trial. Thromb Haemost. 2018;118(8):1409–18.
doi: 10.1055/s-0038-1666862
pubmed: 29972861
pmcid: 6202927
Senguttuvan NB, et al. Comparison of the effect of Morphine and Fentanyl in patients with acute coronary syndrome receiving Ticagrelor - The COMET (Comparison Morphine, Fentayl and Ticagrelor) randomized controlled trial. Int J Cardiol. 2021;330:1–6.
doi: 10.1016/j.ijcard.2021.02.037
pubmed: 33600846
Porter KM, et al. Management of trauma pain in the emergency setting: low-dose methoxyflurane or nitrous oxide? A systematic review and indirect treatment comparison. J Pain Res. 2018;11:11–21.
doi: 10.2147/JPR.S150600
pubmed: 29302193
von Vopelius-Feldt J, Wood J, Benger J. Critical care paramedics: where is the evidence? A systematic review. Emerg Med J. 2014;31(12):1016–24.
doi: 10.1136/emermed-2013-202721
Kill, C., Greb, I., Wranze, E. et al. , Kompetenzentwicklung im Rettungsdienst. Notfall Rettungsmed 04/2007.
I. Greb, E.W., H. Hartmann, H. Wulf, C. Kill, Analgesie beim Extremitätentrauma durch Rettungsfachpersonal. Daten zu Sicherheit und Wirksamkeit bei präklinischer Morphingabe. Notfall Rettungsmed, 02/2011.
Haske D, et al. Prehospital analgesia performed by paramedics: quality in processes and effects under medical supervision. Anaesthesist. 2014;63(3):209–16.
pubmed: 24562597
Flemming A, Adams HA. Analgesia, sedation and anaesthesia in emergency service. Anaesthesiol Reanim. 2004;29(2):40–8.
pubmed: 15168940
Gnirke A, et al. Analgesia in the emergency medical service: comparison between tele-emergency physician and call back procedure with respect to application safety, effectiveness and tolerance. Anaesthesist. 2019;68(10):665–75.
doi: 10.1007/s00101-019-00661-0
pubmed: 31489458