Prehospital pain management of traumatically
injured adult patients
Stig Benström
Magisterprogrammet i klinisk farmaci HT-18 – VT-20
Handledare
MSc Clin. Pharm. Jana Lass, Tartu University Hospital
Examinator
Elisabet Nielsen
Magisterprogrammet i klinisk farmaci
Institutionen för farmaceutisk biovetenskap
Avdelningen för farmakokinetik och läkemedelsterapi
Farmaceutiska fakulteten
Uppsala Universitet
2 ABSTRACT(ESCP)
Title
Prehospital pain management of traumatically injured adult patients Authors
Benström S Institute
Uppsala University, Uppsala, Sweden Background and objective
Traumatic injuries are a major cause behind moderate and severe pain in a prehospital setting. Therefore, the aim of this study is to evaluate prehospital use of analgesics among adult traumatically injured patients treated within Tartu Ambulance Foundation by analysing how ambulance personnel evaluates and treats pain. Secondary aim is to map prehospital factors influencing the process.
Setting and Method
A retrospective, single-centre service evaluation study with the primary selection of 7526 electronic patient records (EPR) with the main diagnosis of S00-T98 (ICD-10) was conducted and a polyvariant logistic regression model was created to map factors that influence pain management.
Main outcome measures
Primary outcome measures were prevalence of pain evaluation and the use of analgesics. Secondary outcome measures were significant changes in odds ratios for prehospital-related factors that affected primary outcome measures.
Results
Mean age of the study population was 54 years (SD 22) and 775 (58.9%) were male. Out of all the patients in this study 529 (40.3%) received analgesics.
Pain assessment before administrating analgesics was documented on 15.9% of EPRs. Nurses assessed pain 3.3 times (95% CI 2.0-5.3; p<0.001) more likely than physicians. The odds for receiving analgesics were 2.3 (95% CI 1.68-3.08; p < 0,001) times smaller when patients had consumed alcohol.
Brief assignment (0-10 min) and hospitalisation reduced the odds of using analgesics by 3.6 times (95% CI 1.9-6.8; p<0,001) and 1.59 times (95% CI 1.13-2.24; p<0.007) respectively while lengthy assignments (>50 min) increased the odds by 3.4 times (95% CI 1.9-6.5; p<0,001).
Monotherapy was chosen for 73.2% of patients while 24.6% received a combination of 2 and 2.2% a combination of 3 analgesics.
Conclusions
Current study showed that although nurses as brigade leaders are more likely to assess pain the overall prevalence remains low. Alcohol consumption among patients, short assignment times, and hospitalization decreased the odds for pharmacological pain management. Longer
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assignment times on the contrary were associated with increased odds. Improvements in pain management can be made in choosing between specific therapeutic options.
4 TABLE OF CONTENTS ABSTRACT (ESCP) ... 2 INTRODUCTION ... 5 METHODS ... 6 Background ... 6 Study design... 6 Data collection ... 6 Exclusion criteria ... 6 Data analysis ... 6 Ethical considerations ... 7 RESULTS ... 8 Study population ... 8
Brigade procedures and routines ... 9
Pharmacological pain management ... 11
DISCUSSION... 12
Strengths and limitations ... 13
Conclusions ... 13
5 INTRODUCTION
Prevalence of acute pain in the prehospital setting is estimated to be around 20-35% (1) (2) (3). While associated diagnoses are heterogenic, it seems that traumatic injuries are a major cause behind moderate and severe pain among those patients.
Adequate pain management throughout the episode of care as well as in the prehospital setting is associated with increased perception of quality of care (4), reduced burden of medical care and shortened recovery period in hospitals (5) (6). Achieving analgesia in traumatically injured patients in the prehospital setting is challenging. Previous studies in this patient population have reported undertreatment of acute pain affecting 60-90% of patients (7) (8) and infrequent pain assessment varying between 20-50% (8) (9) (10) as common shortcomings.
Pain evaluation and re-evaluation are an essential part of pain management. Assessment of the severity of pain enables the selection of adequate pharmacological treatment while re-evaluation ensures that chosen therapy has been effective or indicates the need for adjustments of the regimen. A review from the United Kingdom about commonly used pain rating scales state that VAS (Visual Analogue Scale), NRS (Numerical Rating Scale) and VRS (Verbal Rating Scale) are all valid tools in clinical practice (11). However, according to a guideline from the United States, where authors had analysed 54 studies about pain evaluation, a specific scale cannot be preferred over the others in a prehospital setting (12). Instead they stress the need to be aware of different tools and use them in accordance with patients age, communication skills and ability to comprehend what is asked.
There are several common factors that lead to unrelieved pain and unachieved analgesia in a prehospital setting. Poor adherence to recommendations to always assess pain in traumatically injured patients, guideline recommended pharmacological treatment options and reassessment of pain for all the patients who have received analgesia have been brought up. Therefore, the aim of the study is to evaluate prehospital use of analgesics among adult traumatically injured patients treated within Tartu Ambulance Foundation (TAF) by analysing how ambulance personnel evaluates and treats pain. Secondary aim is to map prehospital factors that influence the process.
6 METHODS
Background
Tartu Ambulance Foundation (TAF) provides emergency medical service at 15 locations in the south-eastern region of Estonia and was dispatched to 59 807 incidents in 2018. Service is provided by 26 ambulance brigades, which consist of an emergency medical technician, nurse and a brigade leader who is either a nurse or a physician.
Study design
A retrospective, single-centre service evaluation study of prehospital pain management was conducted at the TAF. Electronic patient records (EPRs) of traumatically injured adult patients treated by ambulance service in one year (1st of January 2018 – 31st of December 2018) were
analysed.
Data collection
The primary selection out of 59807 EPRs included 5989 EPRs with main diagnosis of S00-S99 (injuries related to single body regions) and 1537 with main diagnosis of T00-T98 (injuries to multiple or unspecified body regions as well as certain other consequences of external causes). This selection was followed by detailed analysis of 1505 (20%) randomly chosen EPRs. Data from the EPRs included: age, sex, diagnosis, alcohol consumption, chosen treatment (pharmacological and non-pharmacological) including data about patients’ self-medication, specialty of the brigade leader, pain assessment and respective scores, length of assignment and hospitalization.
Patient was considered being under the influence of alcohol when the brigade leader assessed and documented it in the corresponding section on the EPR with or without patients themselves admitting alcohol consumption. TAF does not measure alcohol in either blood or exhaled air.
For the purpose of this study the length of an assignment was measured from the moment the brigade arrived to the scene until leaving the patient either at the scene if deemed appropriate or to the hospital (including the transportation time from the scene to hospital).
Exclusion criteria
EPRs about cardiovascular resuscitation, traumas caused by poisoning or allergic reactions, interhospital transport, suicide or suicide attempts or foreign bodies in respiratory tract were excluded from the further analysis since those were not regarded as trauma that primarily requires pharmacological pain management. Patients younger than 18 years were excluded from the study.
Data analysis
Descriptive statistics were used to describe the study population. Quantitative variables are presented as proportions, means and standard deviations. Categorical variables are presented as proportions.
A logistic regression model was created using R (version 3.6.3) to evaluate how different prehospital-related factors affect the decision to assess the intensity of pain, decision to use
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prehospital analgesia and how selection of different analgesics could be associated with those factors. Both patient- and service-related factors were included to see which ones show stronger correlation with aforementioned questions. Factors that were included in the model were as follows: age groups (5 years), sex, diagnosis groups (S00-S09 - Injuries to the head, S10-S19 Injuries to the neck, etc.), alcohol consumption, decision to administrate analgesics, patients’ self-medication, brigade leader, decision to assess pain, length of ambulance assignment (10 minute intervals), hospitalization and 4 analgesics (paracetamol, tramadol, diclofenac and pethidine). Odds ratios (OR) adjusted for all the variables in the model with 95% confidence intervals (CI) were calculated for the variables. A probability score of less than 0.05 was accepted as statistically significant.
Ethical considerations
Following aspects were discussed to get an approval from the Research Ethics Committee of the University of Tartu (15th of April 2019 292/T-10):
• Patient identification is possible only at the TAF by using medical history number. Recording this number for the purpose of data collection is important to avoid making mistakes when analysing the data.
• Data from the medical history records will be maintained in the personal computer of the student who is conducting the research.
• Dataset will not be forwarded electronically. Data will be collected directly to the personal computer of the student who is conducting the research.
• Dataset with the medical history numbers will be preserved during analysis of the results.
• Data will be used to write a report for the master’s curriculum in Clinical Pharmacy at the Uppsala University.
• Collecting an informed consent for the purpose of this study is not possible due to the retrospective design. All the results will be published as scientific generalizations.
8 RESULTS
Study population
A total of 7526 adult patients treated by the TAF had a main diagnose of interest. Out of those patients 1505 (20%) were randomly picked and investigated. Approximately 12% (191) of EPRs met the exclusion criteria. Out of remaining 1314 EPRs analysed in detail, 529 (40.3%) included information about prehospital use of analgesics (Figure 1).
Figure 1 Patient flow chart illustrating selection of patients into the study
Mean age in study population was 54 years (SD 22) and 775 (58.9%) were male. Mean age in the pharmacological treatment group was 48 years (SD 20) for male and 65 years (SD 22) for female patients. Respective numbers among patients who did not receive pharmacological treatment were 47 (SD 19) and 61 (SD 23). Of all the patients who did not receive analgesics 124 (15.8%) refused to take them. Most common injuries among study population can be found in table 1. Alcohol consumption among patients who received analgesics was mentioned on 66 (23.4%) male EPRs and 26 (10.4%) female EPRs. Corresponding numbers among patients who did not receive analgesics were 262 (52.7%) for males and 47 (16.2%) for females. Results from the logistic regression model (Table 2) showed that while patients’ age and sex did not impact the decision to use analgesics the odds for receiving analgesics were 2.3 (95% CI 1.68-3.08; p<0.0001) times smaller when patients were under the influence of alcohol. No. of incidences in TAF in 2018 N = 59807 Primary selection (Main diagnosis - Ch. XIX ICD-10 (S00-T98); Adult patients N = 7526 EPRs analyzed in detail N = 1314
No. of EPRs - with the use of analgesics
N = 529 No. of EPRs - without
the use of analgesics N = 785
No. of excluded EPRS N = 191 20% randomly
chosen EPRs were investigated
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Table 1 Common locations of injury among study population separately for female and male patients according to
diagnosis codes (ICD-10)
N – EPRS; (%) PATIENTS RECEIVING PHARMACOLOGICAL TREATMENT
529 (40.3)
PATIENTS NOT RECEIVING PHARMACOLOGICAL TREATMENT
785* (59.7)
MALE Diagnose N (%) Diagnose N (%)
1ST S20 24 (8.6) S01 117 (23.6) 2ND S82 24 (8.6) S00 84 (17.0) 3RD S01 21 (7.5) S61 37 (7.5) FEMALE 1ST S72 44 (17.7) S00 49 (16.9) 2ND S52 16 (6.43) S01 47 (16.2) 3RD S00 15 (6.02) S61 23 (7.9)
S00 - Superficial Injury Of Head, S01 - Open Wound Of Head, S20 - Superficial Injury Of Thorax, S52 - Fracture Of Forearm, S60 - Superficial Injury Of Wrist And Hand, S61 - Open Wound Of Wrist And Hand, S72 - Fracture Of Femur, S82 - Fracture Of Lower Leg, Including Ankle.
Table 2 Summarized results of associations between patient related factors and the decision to use prehospital
analgesia
DECISION TO USE PREHOSPITAL ANALGESIA
CHARACTERISTICS Model estimate SE OR (95% CI) p-value
Age groups (years)*
15-20 0.44862 0.40278 1.57 (0.71-3.45) 0.26 20-25 0.20751 0.35353 1.23 (0.62-2.46) 0.55 25-30 0.20418 0.35490 1.23 (0.61-2.46) 0.55 30-35 Reference - - - 35-40 -0.07505** 0.37412 1.08 (0.52-2.24) 0.84 40-45 0.35732 0.36067 1.43 (0.70-2.90) 0.32 45-50 0.10121 0.34401 1.11 (0.56-2.17) 0.76 50-55 -0.25981 0.35157 1.30 (0.65-2.58) 0.45 55-60 -0.57056 0.37773 1.77 (0.84-3.71) 0.13 60-65 -0.09565 0.36197 1.10 (0.54-2.24) 0.79 65-70 0.34603 0.38311 1.41 (0.67-2.99) 0.36 70-75 -0.34548 0.42113 1.41 (0.62-3.22) 0.41 75-80 -0.33839 0.36901 1.40 (0.68-2.89) 0.35 80-85 0.06676 0.36326 1.07 (0.52-2.18) 0.85 85-90 -0.63073 0.38476 1.88 (0.88-3.99) 0.10 90-105)*** -0.32012 0.44645 1.38 (0.57-3.30) 0.47 Sex female 0.06673 0.14681 1.07 (0.80-1.43) 0.64 male Reference - - - Alcohol consumption -0.82385 0.15413 2.28 (1.68-3.08) <0.0001
*Most prevalent age group 30-35 was used as a reference when comparing the use of prehospital analgesia between different age groups.
**Negative model estimate means negative correlation between analysed factors and their impact on pain management.
***Patients older than 90 years were considered as one age group due to low representation compared with other age groups.
OR – odds ratio; SE – standard error
Brigade procedures and routines
Mean time spent on assignment where analgesics were administrated was 42 minutes (SD 30) and 28 minutes (SD 22) on assignments where analgesics were not used. Out of 529 patients who received analgesics 357 (67.5%) were hospitalized whereas hospitalization rate among patients who did not receive analgesics was 53% (417). Pain assessment before drug treatment was documented for 15 (7.5%) physician led brigades and for 69 (20.9%) brigades led by a nurse. Re-evaluation by physicians was done in 2 (1%) occasions and in 14 (4.2%) occasions by nurses. According to EPRs the most common pain rating scale was VAS (N = 81; 96.5%) alongside with the NRS (N = 3; 3.5%). Information about the pain scores could
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mostly be found in the “free text” sections despite the special section for VAS on EPRs. Non-pharmacological treatment was more common in patients who also received analgesics (table 3). Regression analysis (Table 4) showed that in a similar setting having a nurse or a physician as a brigade leader does not affect the decision to administrate analgesics. However, brief assignment (0-10 min) reduced the odds of using analgesics by 3.9 times (95% CI 2.1-7.6); p<0.001) while longer assignments (>50 min) increased the odds by 3.4 times (95% CI 1.8-6.5; p<0.001). Model also showed 1.59 (95% CI 1.13-2.24; p<0.007) times smaller odds for giving analgesics when patients were hospitalized. In regards of pain assessment nurses assess intensity of pain 3.3 times (95% CI 2.0-5.3; p<0.001) more than physicians.
Table 3 Ambulance routines that affect management of traumatically injured patients in the study population N – EPRS; (%) PATIENTS WTH PHARMACOLOGICAL TREATMENT 529 (40,3) PATIENTS WITHOUT PHARMACOLOGICAL TREATMENT 785 (59,7) BRIGADE LEADER - N (%) DOCTOR 199 (37,6) 292 (37,1) NURSE 330 (62,4) 494 (62,9) PAIN ASSESSMENT - N (%) DOCTOR BEFORE ANALGESICS 15 (7,5) 8 (2,7) AFTER ANALGESICS 2 (1) NA NURSE BEFORE ANALGESICS 69 (20,9) 47 (9,5) AFTER ANALGESICS 14 (4,2) NA NON-PHARMACOLOGICAL TREATMENT - N (%)* YES 186 (35,2) 87 (11,1)
*application of external splint, cold or local anaesthesia
Table 4 Summarized results of associations between brigade procedures and routines and the decision to use
prehospital analgesia and the decision to assess pain
DECISION TO USE PREHOSPITAL ANALGESIA
CHARACTERISTICS Model estimate SE OR (95% CI) p-value
Brigade leader Nurse -0.20516* 0.13879 1.23 (0.94-1.61) 0.13 Doctor Reference - - - Length of assignment (minutes)** 0-10 -1.38452 0.33038 3.99 (2.09-7.63) <0.0001 10-20 -0.58663 0.25412 1.80 (1.09-2.96) 0.02 20-30 -0.03220 0.23841 1.03 (0.65-1.65) 0.89 30-40 Reference - - - 40-50 0.24973 0.28308 1.28 (0.74-2.24) 0.38 50-60 1.23524 0.32178 3.44 (1.83-6.46) 0.0001 60-300*** 0.8695 0.26728 2.39 (1.41-4.03) 0.001 Length unknown -0.10794 0.25531 1.11 (0.68-1.84) 0.67 Hospitalization -0.46407 0.17446 1.59 (1.13-2.24) 0.007 DECISION TO ASSESS TRAUMA RELATED PAIN
CHARACTERISTICS Brigade leader
Nurse 1.192287 0.243862 3.29 (2.04-5.31) <0.0001
Doctor Reference - - -
*Negative model estimate means negative correlation between analysed factors and their impact on pain management.
**LOA – length of assignment; Assignments that lasted 30-40 minutes were used as a reference for other
intervals.
***Assignment lengths longer than 60 minutes were considered as one group because of the low representation of intervals above 60 minutes.
11 Pharmacological pain management
Of all the patients who received analgesics, 73.2% (387) received monotherapy while 24.6% (130) received a combination of 2 and 2.2% (12) a combination of 3 analgesics. The most common choice for monotherapy was either paracetamol (N = 149; 38.5%) or tramadol (N = 83; 21.5%). Half of the paracetamol as monotherapy (50.3%) was used intravenously and 1g was administrated for all the patients regardless of the route of administration. Most of the tramadol (N = 70; 84.3%) was used intravenously while 50mg was the most prevalent (72.9%). dose used via this route. A total of 13 different analgesic combinations were used in the study population. However, orally administrated combination of diclofenac with paracetamol (N = 41; 31.5%) and intravenously administrated tramadol with paracetamol (N = 23; 17.7%) were the most common combinations. Out of 202 (38.2%) patients who received opioids 99 (49.0%) got concomitant metoclopramide injection for reducing the risk of nausea. While 31 patients out of 103 (30.1%) received intramuscular diclofenac as monotherapy or in combinations with other drugs this route of administration was documented overall on 55 (10.4%) EPRs. Analgesics were used before the arrival of ambulance by 28 patients (5.3%) among the analgesic treatment group and by 37 patients (4.7%) who did not receive additional analgesics from the ambulance. Details about the pharmacological pain management can be found in table 5. The only relevant association when including four analgesics into the regression model, were between tramadol, pethidine and hospitalization. The odds of being hospitalized was 3.29 times higher (CI 95% 1.32-8.22; p<0.01) when brigade had administrated tramadol (Table 6) and 22 times (95% CI 5.37-91.88; p<0.001) higher with pethidine compared to the same situations without those analgesics.
Table 5 Details of pharmacological pain management, choice of analgesics, doses, and routes of administration in monotherapy and combination of 2 or 3 pharmaceuticals
N - EPRS
MONOTHERAPY
ANALGESIC - N (%) 1st – N (%) 2nd – N (%) 3rd – N (%)
INN - N (%) paracetamol 149 (38.5) tramadol 83 (21.5) diclofenac 52 (13.4) INN, OPIOID - N (%) tramadol 83 (21.5) pethidine 46 (11.9) morphine 4 (1.0)
PARACETAMOL IV IM PO FREQUENCY - N (%) 75 (50.3) NA 74 (49.7) DOSE, MG (% of N) 1000 (100.0) NA 1000 (100.0) TRAMADOL IV IM PO FREQUENCY - N (%) 70 (84.3) 13 (15.7) NA DOSE, MG (% of N) 50 (72.9) 50 (76.9) NA DICLOFENAC IV IM PO FREQUENCY - N (%) NA 26 (50.0) 26 (50.0) DOSE, MG (% of N)) NA 75 (100.0) 100 (53.8) PETHIDINE IV IM PO FREQUENCY - N (%) 44 (95.7) 2 (4.3) NA DOSE, MG (% of N)) 50 (56,5) 50; 100 (50.0) NA COMBINATION OF 2 PHARMACEUTICALS
COMBINATION Frequency - N (%) Doses, mg (%of N) Route of administration
DICLOFENAC AND PARACETAMOL 41 (31.5) 100 + 1000 (46.3) PO IBUPROFEN AND PARACETAMOL 25 (19.2) 400 + 1000 (88.0) PO TRAMADOL AND PARACETAMOL 23 (17.7) 50 + 1000 (91.0%) IV
COMBINATION, OPIOID Frequency - N (%) Doses, mg (%) Route of administration
TRAMADOL AND PARACETAMOL 23 (17.7) 50 + 1000 (91.0) IV PETHIDINE AND PARACETAMOL 11 (7.6) 50 + 1000 (34.8) IV
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MORPHINE AND PARACETAMOL
5 (3.9) 2, 4, 5, 7, 10 + 1000 (0.77) IV
COMBINATION OF 3 PHARMACEUTICALS
COMBINATION Frequency - N (%) Doses, mg (% of N) Route of administration
DICLOFENAC, PARACETAMOL AND DICLOFENAC
4 (33.3) 100 + 1000 + 50 (100.0) PO
Table 6 Summarized results of associations between opioid analgesics and hospitalization HOSPITALIZATION
CHARACTERISTICS Model estimate SE OR (95% CI) p-value
Analgesic Tramadol 1.19064 0.46762 3.29 (1.32-8.22) 0.01 Pethidine 3.1003 0.7246 22.2 (5.37-91.88) <0.0001 SE – standard error OR – odds ratio DISCUSSION
It is estimated that nearly 1 in 5 patients transported to hospitals by ambulance are in moderate to severe pain and nearly 1/3 of the causes is a traumatic injury (1). Our study showed that less than half of the traumatically injured patient population receive pharmacological management in the TAF. Moreover, 53.1 % of patients in the current study who did not receive pharmacological treatment were still hospitalized. These results concur with the results of the logistic regression model where hospitalization was associated with lower tendency to use analgesics. This can be an indicator for insufficient treatment of traumatically injured patients who are eligible for pharmacological pain management. Patients’ alcohol consumption however could have contributed to abstaining from pharmacological pain management. Pain evaluation in different prehospital settings can vary greatly between 20% to 90% (9) (10) (13) (14). A qualitative study from the Netherlands pointed out possible barriers in pain management for trauma patients (15). Pain assessment based on experience, pain management based on expert opinions as well as focus on „treat first what kills first“ and doubts about patients pain can all be obstacles to achieving effective analgesia. Despite the existing internal guidelines at the TAF that insist on pain evaluation by using either VAS or VRS, the assessment of pain scores was registered in 7.5% of the EPRs signed by physicians and in 20.9% EPRs signed by nurses. Although a nurse as brigade leader is more likely to assess pain in TAF the overall adherence to guidelines remains low. This could affect choosing an adequate treatment and as a result, patients’ perception of quality of care. Interestingly, it seems that nurses and physicians use analgesics in a similar manner despite the gap in assessment of pain.
According to this study paracetamol followed by tramadol, were most common single analgesics used to alleviate pain in traumatically injured patients. Interesting to note is that a combination of paracetamol and diclofenac or tramadol are not so common as using both analgesics as monotherapy. A Review of the pharmacological pain management in trauma patients in pre-hospital emergency medicine in the Netherlands concluded that paracetamol is widely used and appears to be effective analgesic, administrated both orally and intravenously (16). Same authors stated also that although NSAIDs are potential agents for pain relief they have many contraindications and can cause serious side effects. Due to the limited time frame and restricted possibilities to assess those risks in a pre-hospital setting in traumatically injured patients it is questionable whether they should even be recommended to use as monotherapy in this setting. Studies that compare effectiveness between paracetamol and diclofenac have shown that paracetamol, both orally and intravenously is not inferior to
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diclofenac and its’ combination with paracetamol (17) (18) as well as not inferior to intravenous tramadol (19). Although one tenth of analgesics were administrated intramuscularly it is important to further discourage the use of this route of administration since it does not allow for dose titration, the effect is difficult to predict and it can cause unnecessary additional pain and potential harm.
Apart from tramadol the most common opioid used in patients in this study was pethidine. In contrast to morphine, pethidine is less effective in alleviating moderate to severe pain and is associated with adverse neurological effects like serotonin syndrome, anticholinergic effects, negative effects on the mood and CNS (central nervous system) excitation (20). Use of pethidine should be discouraged mainly because of its’ inferior efficacy as an analgesic as well as the same issues as emerged with NSAIDs. B. M. Dijkstra et al. discussed in their review that despite the risk for respiratory or cardiovascular depression, both intravenous morphine and fentanyl are safe and effective opioids in pain management in a prehospital setting (16). Study also showed that concomitant use of opioids and metoclopramide is quite common. A meta-analysis of 595 trauma patients who received intravenous morphine at a dose of 10 mg showed that the incidence of vomiting following the administration of intravenous morphine for pain relief in the emergency setting was negligible (21). Furthermore, there was no statistical difference in the incidence of vomiting either with or without concomitant administration of metoclopramide. These results can not directly be applied to the current study because of the relatively low frequency of morphine use. However, it must be considered that using metoclopramide itself might expose patients to unnecessary adverse effects.
Strengths and limitations
A broad spectrum of trauma related diagnoses with comprehensive dataset about each patient and the amount of EPRs that were included into the study allows to apply the results and accurately describe prehospital trauma related pain management in the Tartu Ambulance Foundation. Results can therefore be applied for the educational purposes inside the foundation to improve patient care.
On the other hand, this study has also some limitations. The results in this study are based on a single ambulance foundation that represents a quarter of the ambulance brigades working in Estonia and less than half of the total assignments for all the ambulances.
Another limitation is that the results in this study are retrospective and based on ambulance personnel’s documentation; therefore, there is a possibility that procedures like pain assessment and re-evaluation, were performed but not properly documented. For example, mentioning of pain as a symptom could be found in the free text sections on some of the EPRs but it was quite often done in an unstandardized manner without assessment or categorization. As a result, it was difficult to include this data into the study.
Conclusions
In conclusion the study showed that a nurse as brigade leader is more likely to assess pain in TAF but the overall adherence to guidelines remains low. While this does not seem to affect the decision to administrate analgesics our modelling showed that patients’ alcohol consumption, short assignment times, and hospitalization decreased the odds for pharmacological pain management. Longer assignment times on the other hand were associated with increased odds. Paracetamol, tramadol, and diclofenac alone and in combinations were most common therapeutic options and study showed that tramadol and pethidine are associated with higher hospitalisation rates. Improvements in the quality of pain
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management at the TAF can be made in regards of pain assessment and choosing between specific therapeutic options.
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