Analgesic Therapy with the Opioids Fentanyl and Morphine by Ambulance Personnel in Rural Areas: An Observational Study Over 7 Years

Abstract

Background

The treatment of severe pain is one of the basic procedures of emergency medicine. In rural regions, longer arrival times of the emergency doctor prevent the earliest possible treatment of pain. Since 2014, a project for independent analgesia by ambulance personnel has been introduced in our ambulance service area.

Methods

Over a period of 7 years the mission protocols were recorded and statistically evaluated within the framework of an observational study. Among other things, the attendance and transport times, vital signs, pain level, symptom groups (body region) and classification according to disease or accident mechanism were recorded. Treatment data by medication, including dosages, were recorded for fentanyl (monotherapy), morphine (monotherapy) and a combination (change from morphine to fentanyl, additional application of esketamine, metamizole or butylscopolamine).

Results

In 659 patients, the opioids fentanyl and morphine were used by the ambulance staff, 596 data sets could be evaluated. When an emergency physician was requested, the average time of presence at the scene was 34.8 +- 11.7 min, in cases of unavailability it was 29.0 +-9.8 min (p<0.0001). Analgesic therapy resulted in a reduction of pain from NRS 8.4 (+-1.3) to NRS 3.5 +-1.8 (p<0.0001). Pain intensity after treatment by emergency paramedics compared to emergency physicians was not significantly different with NRS 3.5 +- 1.7 versus NRS 3.6 +-1.9 (p=0.788). Fentanyl was used at a mean dose of 0.18mg +- 0.11 and morphine at a mean dose of 4.4mg +- 3.6mg. There was no clinically relevant decrease in oxygen saturation or respiratory rate in any of the treatment groups. Antagonisation of the opioid effect with naloxone was not necessary in any case.

Conclusion

Analgesia with morphine and fentanyl by specially trained ambulance personnel according to defined rules of use is a safe and necessary procedure for patients, especially in rural regions.

Keywords:

• prehospital
• analgesia
• opioids
• paramedics

Abbreviations

NRS, numeric rating scale; NRS^i, numeric rating scale, at initial contact with patient; NRS^h, numeric rating scale at handover in the hospital; BOS, radio for authorities and organizations with security tasks; EP, emergency physician; PM, emergency paramedic; GCSⁱ, Glasgow Coma Scale at the initial contact; GCS^h, Glasgow Coma Scale at handover in the hospital; RRⁱ, respiratory rate at initial contact; RR^h, respiratory rate at handover in the hospital; BPsysⁱ, systolic blood pressure at initial contact; BPsys^h, systolic blood pressure at handover in the hospital; HRⁱ, heart rate at initial contact; HR^h, heart rate at handover in the hospital; spO2ⁱ, oxygen saturation at initial contact; spO2^h, oxygen saturation at handover in the hospital; NACA, National Advisory Committee for Aeronautics score; MWU, Mann–Whitney-U test; KW, Kruskal–Wallis test; WVR, Wilcoxon signed-rank test.

Data Sharing Statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics Approval and Consent to Participate

The Ethics Committee of the Lower Saxony Medical Association gave a positive vote for the retrospective evaluation of the anonymised intervention data (statement by the Ethics Subcommittee of the Lower Saxony Medical Association dated 12 January 2017):

In the opinion of the Subcommittee for the Assessment of Medical Research Involving Human Subjects of the Ethics Committee at the Medical Association of Lower Saxony (ÄKN), the retrospective data evaluation planned by you is not a research project in which the psychological or physical integrity of a human being is interfered with or body materials or data are used that can be assigned to a specific human being.

Provided that the personal patient data do not leave the circle of physicians who are obliged to remain silent anyway and who are involved in the treatment of the patient, including auxiliary staff, consultation with the ethics committee in accordance with § 15 of the professional regulations of the ÄKN is therefore not necessary. We strictly adhered to all provisions.

The study has been performed in accordance with the Declaration of Helsinki. All methods were carried out in accordance with relevant guidelines and regulations in the declaration.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests in this work.