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24 Prehospital analgesia
care providers as an adjunct for procedural sedation and analgesia, may have
prehospital utility in some settings, but more data are required before its EMS
use can be endorsed. 38
Alfentanil is similar to fentanyl and is demonstrated comparable to morphine
when used by physician-staffed (Finnish) EMS in cardiac patients. 39
There are no available data describing its effectiveness in other prehospital
populations, and it is premature to recommend adoption of alfentanil for
routine prehospital use.
Two other opioids, with agonist–antagonist activity, have also been studied
for use in the field. Nalbuphine has been in use for decades in the USA and is also
employed in the UK. Those who use the agent report favorably on its performance,
but more robust data are needed before its widespread deployment in
EMS can be recommended. 40,41 Butorphanol has the advantage that it can be
administered by the intranasal route (i.e. when IV access is lacking). Despite this
potential niche for prehospital use, there is insufficient evidence or experience to
recommend butorphanol’s inclusion in the prehospital pharmacopoeia. 30
The mixed-mechanism agent tramadol is used commonly in some (non-
USA) venues. The drug has its roles in acute care medicine (see other
chapters), but relative lack of trial data and high incidence (30%) of nausea
figure prominently in assessments of tramadol’s role in prehospital care. 12
Tramadol’s opioid characteristics require medical and logistic (e.g. drug
storage) attention, and the drug can also precipitate serotonin syndrome if
used in patients taking monoamine oxidase inhibitors or other serotoninergic
antidepressants. 42 While tramadol is probably effective for EMS use in
some settings, there is little reason to select this agent over morphine.
The use of nonopioids in the out-of-hospital environment remains atypical,
but emerging data seem likely to indicate some role for these agents. The
main non-opioid analgesics discussed in the prehospital analgesia literature
are nitrous oxide, ketamine, and local anesthetic injection for regional
block. These agents are considered next, with the understanding that their
availability may be limited to only a few EMS systems.
Nitrous oxide is the only inhaled agent available for prehospital use in the
USA (other inhalational anesthetics are in use in other countries). Nitrous
oxide has been used in the field for over three decades. 12 It appears safe, is