‘On a scale of zero to ten, how would you rate your pain?’
Prehospital acute pain management research in adults often focuses on analgesic administration: ‘what proportion of patients received an analgesic?’, ‘did a meaningful pain score reduction occur?’, ‘were there any adverse events?’ Pain is best understood using Engel's biopsychosocial model of health as the underpinning framework, where analgesic administration addresses the biological and, to some extent, the psychological remit of pain. The psychosocial component of pain is often underrepresented in clinical research. Our latest systematic review and meta-synthesis (Whitley et al, 2023) aimed to address this gap in the literature.
We synthesised the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults, and generated recommendations to improve quality of care. Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from eight countries.
It was found that prehospital acute pain management in adults requires a holistic approach that promotes patient empowerment, develops trust and addresses patient needs and expectations. While these are broad, high-level recommendations, as individual clinicians, we can adapt these to our local context. For example, to promote patient empowerment, we could create conditions of participation (perhaps by suggesting a range of immobilisation or patient positioning techniques and supporting the patient to find their optimum comfort level), and adapt to the patient's needs (by adjusting the environment [light, noise and temperature level], analgesic regime [increase or decrease dosing] or level of psychosocial support [reassurance, hand holding, relative proximity].
Stronger collaboration across the prehospital-emergency department intersection is also needed to improve the emergency care pathway. As the paramedic profession evolves, we need to seek better integration with emergency departments and other healthcare providers to ensure a seamless patient pathway, which will likely optimise the patient experience and improve quality of care.
Bleeding nightmare—use of tranexamic acid in severe haemorrhage
Traumatic injuries are responsible for 10% of deaths worldwide, and approximately one-third of these patients die as a result of haemorrhage. Tranexamic acid (TXA)— an antifibrinolytic agent which reduces mortality in haemorrhaging trauma patients—is of greatest benefit when administered as soon as possible after injury. This retrospective study from the Netherlands sought to evaluate the prehospital administration of TXA in ambulance-treated trauma patients with a severe haemorrhage following the implementation of a TXA administration protocol.
All patients with a severe haemorrhage, who were treated and conveyed by emergency medical services (EMS) professionals over a 3-year period to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. Severe haemorrhage was defined as extracranial injury with >20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury.
The main outcome was to determine the proportion of patients with a severe haemorrhage who received prehospital treatment with TXA. The relationship between prehospital tranexamic acid treatment and 24-hour mortality was also investigated.
There were 477 patients included in the study, of which 124 (26.0%) received TXA before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe haemorrhage by EMS professionals. The treatment rates were not dissimilar to previous studies, including the 2019 paper by Coats et al from the UK. The authors of this paper estimated that 94% of the patients in the study would have benefitted from prehospital administration of TXA so there is clearly a need to better understand decision-making for administration.
The authors hypothesised that the wording in the guidelines may have contributed to the low administration rate but also cited difficulty in estimating blood loss. Notably, patients treated with tranexamic acid had a significantly lower 24-hour mortality risk than untreated patients (OR 0.43 [95% CI 0.19–0.97]).