Prehospital analgesia for children – or not as the case may be!
Effective analgesia is an integral outcome measure in the prehospital care of children and is a factor that considerably influences parents' perception of the management of their child. Pain management presents multiple challenges owing to inaccurate pain assessment, insufficient knowledge/experience of administering opioids, and fears of adverse effects. Inadequately treated pain can have negative effects on both physical and psychological function of the child, and can lead to long-term effects.
This study by Colding-Jørgensen et al focused on describing prehospital administration of strong analgesics (fentanyl, alfentanil, morphine and/or s-ketamine) to children (<15 years) in the region of southern Denmark. Its focus was on determining the number of children who received strong analgesic treatment when in contact with prehospital emergency care, the analgesic treatment (medication, administration route and dosage) used, as well as the criteria for ambulance dispatch (response and transport time, period spent on scene) and the age/sex of the patient.
This analysis of 28 933 prehospital paediatric medical records revealed that only a small proportion of children (1/17) received administration of strong analgesics, three-quarters of which were aged >10 years. Proportionally, more boys received prehospital analgesia than girls. Fentanyl was the drug of choice for 96.4% of contacts, with an estimated median dose of 1.7 µg/kg. The intravenous route was the preferred route of administration (63.4%) and in 97% of cases, the doses were within the recommended range. Treatment for trauma-related incidents constituted most analgesia administrations. The total time the child was in the care of the emergency medical services (EMS) was a median of 50 minutes, although no comparator was given for those not receiving analgesia. Retrospective studies have limitations, but the conclusions accord with other studies that suggest that there remains a risk of under-treating pain in children.
Does a higher-level EMS qualification improve trauma outcomes? In this study, yes!
Injury remains one of the leading causes of death in younger people and despite advances in prehospital trauma management, research still suggests that between 9 and 56% of trauma deaths may have been preventable. It could be argued that the improvements to date are predicated upon increases in education, training and skillset of the EMS providers attending trauma cases; however, there remains conflicting evidence to support this position.
This retrospective cohort study undertook secondary analysis of a combined prehospital and in-hospital database of trauma patients in the US using electronic medical records from 2018–2022. The researchers included encounters with patients aged 15–100 years transported by ground to a Level I or II trauma centre with trauma-specific ICD-10-CM [International Classification of Diseases, Tenth Revision, Clinical Modification] codes. Those who were dead on arrival of EMS and transfers were excluded from the analysis.
The team matched patients using propensity scores based on demographic, injury, EMS characteristics, prehospital vitals, and trauma centre designation. The EMS level of training was the exposure variable, and outcome was mortality. Helpfully, the researchers also conducted subgroup analyses on predefined cohorts (age>50 years, mechanism of injury, prehospital EMS time>30 minutes).
The study cohort comprised of 32 493 encounters, of which 30 735 were advanced life support (ALS) responses and 1758 basic life support (BLS) responses. The ALS group had significantly higher injury severity scores, different mechanisms of injury, and more interventions; however, there was no significant difference in time spent with the patient. Even when accounting for patient, injury, and trauma centre characteristics, there was an association between trauma patients attended to by ALS-certified EMS providers and decreased mortality. This association was also significant in older patients and those with a high-risk mechanism of injury.
There were limitations typical of any retrospective study. Therefore, results need to be treated with caution; however, it does add important evidence to the debate.