Interventions in fractures of the femur—time for a break for analgesia?
Femoral shaft and neck fractures are painful injuries which, if managed sub-optimally, can lead to a significant increase in length of hospital stay and overall mortality. Early management of these injuries with effective analgesia, splinting and fracture reduction, has been shown to reduce mortality rates and associated complications such as fat emboli. It has also been shown to assist in the management of haemorrhagic shock.
This Australian systematic review focused primarily upon prehospital pain management and the success rates of interventions provided to patients with neck of femur or femoral shaft fractures by non-physicians. The study team undertook a meta-analysis of papers gathered from the search of four databases (Medline, CINAHL, EmBase and Evidence Based Medicine Reviews). Following article screening, 19 papers were included in the final review. The study team extracted data if interventions decreased the patient's pain, if the intervention could be applied successfully, and if there were any adverse events resulting from the intervention. They did note that studies involving traction splints did not report pain scores and so could not be commented upon.
The review identified multiple different pharmacological and non-pharmacological interventions used by paramedics in the management of femoral fractures. These included traction splints, transcutaneous electrical nerve stimulation (TENS), fascia iliaca compartment block (FICB) and pharmacological analgesia. However, the authors noted a general underutilisation of pharmacological analgesia and traction splints with overall usage ranging from 30–60% based on the reviewed evidence. They also recognised the difficulty in commenting on the efficacy of interventions as many of the reviewed papers lacked pre- and post-intervention pain scores. They do note however that interventions such as TENS machines are safe non-invasive options for analgesia and that they do appear to be effective. Alongside this, where appropriately trained clinicians were available, FICB was noted as being a safe and effective analgesic option.
Stress-induced electrocardiogram changes in health emergency medical services physicians
Paramedics are subjected to high levels of stress due to time-critical decision making, physical strain and the uncontrolled environment associated with the prehospital side of the role. Stress has been known to cause ischaemia like changes in electrocardiograms (ECGs), including arrhythmias and deviations in ST-T segments.
Currently, there is limited evidence regarding the occurrence of changes in ST-T segments in prehospital emergency services (EMS) staff, but this study has added some useful data relating to emergency medical services (EMS) physicians. In this prospective observational trial, 12-lead ECGs were recorded on one night shift and one day shift for each of the participants. The primary outcome parameter was defined as the incidence of ST-T segment changes greater than 0.1 mV in two corresponding leads for more than 30 seconds per 100 rescue missions. Secondary outcomes included T-wave inversions and ST-segment changes shorter than 30 seconds or smaller than 0.1 mV.
In all, data were captured from 20 physicians across 36 shifts (18 days, 18 nights), which included a total of 208 missions. All participants had previously been identified as healthy; yet the results of this study showed that 70% experienced at least one ECG abnormality lasting a mean duration of 30 seconds. Significantly more ECG changes were found during night than day shifts (39 vs. 17%, p<0.001) while 49 ECG changes occurred between missions. Two ST-T segment changes of <30 seconds or <0.1 mV (each during missions) were recorded, alongside 122 episodes of T-wave inversions (74 during missions). There did not appear to be a correlation between ECG changes and perceived stressful calls.
It is difficult to know quite what to make of these findings as they are affected by multiple limitations. However, such changes are important signs for high levels of stress even when occurring for less than 30 seconds. There is a need for further work to understand the long-term impact of these changes.