Defence Anaesthesia - Journal of the Royal Army Medical Corps

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Pre-hospital analgesia Data extraction was guided by a Delphi process, in which UK military emergency medicine and anaesthetic consultants were asked about criteria for an ideal pre-hospital analgesic, as well as civilian doctors involved with helicopter emergency services in southern England. Their comments were used to determine which patient outcomes would be sought from included studies, for both efficacy and adverse events. They were asked whether they agreed or disagreed with the following statements regarding adequacy of outcomes: 1. Pain score of
Pre-hospital analgesia CL Park, DE Roberts, DJ Aldington et al Figure 1: Flow of references identified for the systematic review reviews (1,030 patients [36] and 2,129 patients [33]) both looking mainly at adverse events rather than pain scores and effectiveness. Delphi responses Forty of the military anaesthetic and emergency medicine consultants responded to the Delphi exercise, as well as 16 civilian air ambulance doctors; there was good agreement (Table 2). There was a high degree of agreement that analgesia pain should be no worse than mild [16], that pain relief should be rapid (within 10 minutes), that patients should respond to verbal stimuli, not require ventilation, and that major adverse events should be avoided. They were also given an opportunity to make additional comments about what they would find important in pre-hospital analgesia. These were concerned mainly with issues of adverse events, typically the severity of events like nausea and vomiting, and whether cardiovascular stability should also be a criterion for choosing pre-hospital analgesia. Civilian physicians were more accepting of possible adverse events in order to obtain high quality analgesia. Analgesic failure and timing The majority of included studies reported most of the outcomes of interest. Least often reported were the timing of analgesia (within 10-20 minutes; 10/21 studies) and the extent of analgesia (14/21). Need for ventilatory support, sedation, and adverse events were reported in 20/21 studies (Table 1). Many studies provided average pain scores, usually with a standard deviation. Initial average pain scores were above 60/100 mm or equivalent, and typically 80/100 mm. After treatment, pain scores were usually lower, typically averaging 30-40/100 mm, but with standard deviations almost as large as the average, indicating large disparity between individuals. These data were unhelpful in determining failure rate, but did indicate that analgesic failure was occurring. Some studies on opioids [17, 19 – 21, 23 – 27, 33 – 34] provided information on the proportion of patients achieving analgesic success and failure. Figure 2 shows the failure rates (pain ≥30/100 mm) between 10 and 40 minutes after treatment with intravenous morphine, fentanyl, and tramadol, and transmucosal fentanyl. After 10 minutes, about 60-70% of patients still had pain levels above 30/100 mm, but by 30-40 minutes this had fallen to about 30%. There was no obvious difference between opioid chosen in Military (n=40) Number Question Agree (%) 1 Pain score of < 30/100 mm on VAS (or equivalent) achieved Civilian (n=16) this limited data set (Figure 2), and each study used different dose levels and dosing schedules. Failure rates on arrival at hospital were reported as 43% [17] and 17% [19], both involving battle injuries. J R Army Med Corps 156 (4 Suppl 1): S295–300 297 Agree (%) 68 56 2 Rapid onset of action. Pain relief achieved within: 5 minutes 72 100 10 minutes 23 15 minutes 3 20 minutes 3 3 Patients should remain responsive to verbal stimuli 100 75 4 Patient should not require any airway manoeuvres or ventilatory support to be performed following administration 5 Absence of any harmful adverse events following administration 97 88 92 88 Table 2: Results of the Delphi exercise – replies from 40 military anaesthetic and emergency medicine consultants and 16 civilian helicopter emergency service doctors Figure 2: Failure rates (pain greater than 30mm) between 10 and 40 minutes after treatment with intravenous morphine (white), fentanyl (light gray), and tramadol (dark gray), and transmucosal fentanyl (black); the larger the circle’s diameter the larger the number in the study.
Page 1 and 2: Defence Anaesthesia: Conflict Resea
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Page 9 and 10: Pre-hospital Anaesthesia RJ Dawes 1
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Page 23 and 24: TIVA for War surgery S Lewis, S Jag
Page 29 and 30: Role 4 Anaesthesia PR Wood, AG Hald
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Role 4 Critical Care For patients f
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Role 4 Critical Care References 1.
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Maritime Anaesthesia Pre-Operative
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Creating Airway Management Guidelin
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Guidelines for Penetrating Airway I
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The Paediatric Transfusion Challeng
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Paediatric Transfusion S Bree, K Wo
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Simulation, Human Factors and Defen
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Simulation and Defence Anaesthesia
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Simulation and Defence Anaesthesia
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Use of Transoesophageal Echocardiog
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Peri-operative Transoesophageal Ech
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The Triservice Anaesthetic Apparatu
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The Triservice Anaesthetic Apparatu
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Vascular Access on the 21 st Centur
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Vascular Access EJ Hulse, GOR Thoma
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Vascular Access EJ Hulse, GOR Thoma
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Research and Audit
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Epidural Practice Survey When asked
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Evolution of the Role 4 UK Military
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UK Military Pain Service Serial Top
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Society of Triservice Anaesthetic T
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STAT 2010 use to the military healt
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Images of Anaesthesia Gulf War 1991
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