Analgesic Therapy with the Opioids Fentanyl and Morphine by Ambulance Personnel in Rural Areas: An Observational Study Over 7 Years

Olga Scharonow,1 Signe Vilcane,2 Christian Weilbach,2 Maximilian Scharonow2 1Department of Internal Medicine, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany; 2Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, GermanyCorrespondence: Maximilian Scharonow, Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Krankenhausstrasse 13, Cloppenburg, 49661, Germany, Email [email protected]: The treatment of severe pain is one of the basic procedures of emergency medicine. In rural regions, longer arrival times of the emergency doctor prevent the earliest possible treatment of pain. Since 2014, a project for independent analgesia by ambulance personnel has been introduced in our ambulance service area.Methods: Over a period of 7 years the mission protocols were recorded and statistically evaluated within the framework of an observational study. Among other things, the attendance and transport times, vital signs, pain level, symptom groups (body region) and classification according to disease or accident mechanism were recorded. Treatment data by medication, including dosages, were recorded for fentanyl (monotherapy), morphine (monotherapy) and a combination (change from morphine to fentanyl, additional application of esketamine, metamizole or butylscopolamine).Results: In 659 patients, the opioids fentanyl and morphine were used by the ambulance staff, 596 data sets could be evaluated. When an emergency physician was requested, the average time of presence at the scene was 34.8 +- 11.7 min, in cases of unavailability it was 29.0 +-9.8 min (p< 0.0001). Analgesic therapy resulted in a reduction of pain from NRS 8.4 (+-1.3) to NRS 3.5 +-1.8 (p< 0.0001). Pain intensity after treatment by emergency paramedics compared to emergency physicians was not significantly different with NRS 3.5 +- 1.7 versus NRS 3.6 +-1.9 (p=0.788). Fentanyl was used at a mean dose of 0.18mg +- 0.11 and morphine at a mean dose of 4.4mg +- 3.6mg. There was no clinically relevant decrease in oxygen saturation or respiratory rate in any of the treatment groups. Antagonisation of the opioid effect with naloxone was not necessary in any case.Conclusion: Analgesia with morphine and fentanyl by specially trained ambulance personnel according to defined rules of use is a safe and necessary procedure for patients, especially in rural regions.Keywords: prehospital, analgesia, opioids, paramedic

Project for the introduction of prehospital analgesia with fentanyl and morphine administered by specially trained paramedics in a rural service area in Germany

Maximilian Scharonow,1 Timo Alberding,2 Wolfgang Oltmanns,2 Christian Weilbach1 1Department of Anaesthesia, Intensive Care, Emergency Medicine and Pain Therapy, St Josefs-Hospital, 2Deutsches Rotes Kreuz Kreisverb&auml;nde, Cloppenburg, Germany Background: In patients with serious illness or trauma, reduction of severe pain is a key therapeutic goal of emergency medical service (EMS) teams. In Germany, only physicians are allowed to use opioid analgesics. In the rural EMS area studied, the mean arrival time for paramedics is 8 minutes, 23 seconds, and for the rescue physician between 10 minutes, 30 seconds and 16 minutes, 59 seconds, depending on EMS site. In cases of parallel callouts, rescue-physician arrival times may be considerably longer.Objective: During this project, we assessed the administration of the opioid analgesics morphine and fentanyl by specially trained paramedics with regard to analgesia quality and patient safety.Materials and methods: During the 18-month study period, specially trained paramedics administered morphine or fentanyl to patients with severe pain if indicated and if a rescue physician was not available in time. Besides basic documentation, pain intensity (using a numeric rating scale) and oxygen saturation were measured initially and at hospital handover.Results: During the 18 months, 4,285 emergency callouts were attended to by the 13 specially trained paramedics of the district (total callouts during this period 21,423). In 77 patients (1.8%), fentanyl (n=53/68.8%) or morphine (n=24/31.2%) was administered. Based on the measurements obtained with the numeric rating scale at the start of treatment (7.9) and upon hospital handover (3.3), pain reduction was 4.52 overall (41.5%, P&lt;0.001): 4.64 with fentanyl (42.9%, P&lt;0.001) and 4.25 with morphine (43.2%, P&lt;0.001). None of the patients had an oxygen saturation &lt;95% at the time of handover, and no patient developed opioid-induced respiratory depression requiring treatment.Conclusion: The results of this study indicate that the administration of opioid analgesics by specially trained and qualified paramedics is safe and effective. Keywords: prehospital analgesia, paramedics, fentanyl, morphin