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Clinical Focus on the use of ENTONOX in Pain Management administration. Despite these observed phenomena, it remains unclear how the administration of nitrous oxide causes the release of endogenous opioids. The analgesic effects of ENTONOX are rapid, observable and reported by users after only four to five breaths. Indeed, the duration of action is very short, making the drug ideal for short procedures and of course allowing a patient to self-manage the administration of their own pain relief. In practice, ENTONOX has very few side effects or contraindications to use and is easily administered. The role of the NHS ambulance service and indeed of the Paramedic profession is developing quickly within the context of the modern NHS. In addition to NHS staff, voluntary services and other providers of urgent and emergency care are developing clinicians and indeed the resources being used to care for patients. Pain remains among the most commonly reported symptoms for the ambulance service and while the technical skill and capability of clinicians increases as well as pharmacological options for managing pain, it is important to remember that basic interventions have the potential to make a significant positive impact on the onward management of many patients in pain. Assessment and scoring of pain is an incredibly important element of treating any pain presentation, whether acute, chronic or acute on chronic. Pain assessment and basic pharmacological and non pharmacological approaches to the management of pain are important as they help not only to calm and engage a patient in the process of further assessment, but help patients to better describe symptomologies, recognise previously undisclosed pain and to better inform the clinician in crafting a care plan which meets the needs of the individual pain sufferer. ENTONOX administration provides a great opportunity, in many cases, to begin the process of pain management quickly and efficiently without the need for ancillary equipment or invasive procedures. The analgesic effect of ENTONOX may in many cases be sufficient to settle a patient adequately to better describe the illness or injury and indeed allow an attending clinician to better develop a multi-modal pain management plan which better suits the pain presentation the patient is experiencing. A significant number of pain assessment strategies exist, for children (Wong-Baker scale, FLACC), adults (Pain analogue scale, pain thermometer) and indeed those with cognitive impairment (Abbey Pain score, DOLORPLUS) and choosing the best scale is imperative in supporting a patient in identifying the nature and severity of their pain as well as supporting the clinician in best managing it. Clinically, ENTONOX administration provides patients with a fast onset and highly effective analgesia without heavy sedation, has anxiolytic and euphoric effects and supports patient relaxation and better patient engagement, providing in many cases a better opportunity for quality patient assessment and patient history. Across available literature, patients report occasional adverse effects, including nausea and vomiting, dizziness, dry mouth (most likely due to the administration of dry gas), tinnitus and rarely more significant symptoms including numbness, dreams or drowsiness the incidence of such effects ranges in literature between 0 and around 30%. The efficacy of ENTONOX as a pain relieving agent and indeed quantifying actual clinical effectiveness is an area with a relative paucity of evidence. Donen et al. (1982) reviewed the cases of 240 patients to whom ENTONOX had been administered. The population studied had all presented with traumatic injuries to the chest, abdomen or back and were reporting pain. Of those reviewed, over 90% of patients reported reduced pain, with few adverse effects described. Further, in 2007, Descamps et al concluded that the administration of ENTONOX to patients presenting with acute traumatic shoulder dislocations, irrespective of the administration of a further oral analgesic, correlated strongly with markedly reduced time spent within the Accident and Emergency department in contrast to those patients to whom intravenous morphine an intravenous benzodiazepine had been administered. Descamps concluded that the use of morphine and or midazolam 48 Spring 2016 | <strong>Ambulance</strong>today
Clinical Focus on the use of ENTONOX in Pain Management was linked with dramatically increased department stays; 177 minutes for intravenous morphine and / or midazolam and 77 minutes for ENTONOX alone. The paper does not explore the relative efficacy of either option in terms of pain scoring, however does underscore the fast onset and fast resolution of effects of the administration of ENTONOX as well as the clinical utility when used for traumatic injuries. Traditionally, ENTONOX has been a drug used primarily in the management of patients suffering with pain of a traumatic nature or indeed children and labour, however increasingly, evidence supports the use of ENTONOX as an analgesic option for patients suffering a range of conditions including acute heart attack. Nitrous oxide has been observed as exerting relatively minor effects on cardiovascular function in patients diagnosed with coronary artery disease. Two papers, published by Thornton et al. and Wynne et al. concluded that the administration of the nitrous oxide had very little effect on the circulatory system. Further, Wynne postulated that the weak depressant effect exerted on myocardial tissue by nitrous oxide could provide benefit in terms of improving myocardial oxygenation. This, however has not been established as fact, though ENTONOX is a credible and clinically useful option for managing patients by non-registrant clinicians without recourse to opiates and in addition to routine interventions such as nitrates, etc. Pain assessment and management is a major element of the role of the ambulance service and indeed of all those involved with the provision of urgent and emergency care in the UK. ENTONOX remains a highly credible and extremely effective means of rapid pain relief with few side effects or contraindications for use and should remain a cornerstone option for the provision of multimodal pain management in patients presenting with a range of pain conditions. From rocket fuel to pain relief in child birth, nitrous oxide as ENTONOX will likely remain a familiar tool in the side compartment of ambulances, clinics, voluntary agencies and sports clubs up and down the country. Mobile climate control for healthcare professionals Simple to use, effective in performance and reliable in operation. The Eberspächer climate control system. A WORLD OF COMFORT www.eberspacher.com – 01425 480151 Spring jn1001_185x132_mobile_healthcare_atoday.indd 2016 | <strong>Ambulance</strong>today 1 09/02/2016 11:40 49 3
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