In this month’s PTM Journal Club, we explored the most recent literature on trauma care in the pre-hospital setting. If you missed last months PTM Journal Club, make sure to check-it out by clicking HERE.
Ketamine vs Morphine for Out-Of-Hospital Traumatic Pain
Background and Objectives
Inadequate analgesia is a common challenge in the out-of-hospital treatment of patients experiencing pain from trauma. The optimal multimodal analgesia strategy is unknown, and practices vary. More recently, concerns around overprescription and dependence, in addition to the risks of adverse events, have led to limitations on the use of opioid analgesics. At sub-dissociative doses, ketamine is a potent analgesic with a potentially favourable side effect profile. This study sought to determine whether intravenous ketamine is non-inferior to intravenous morphine to provide pain relief to adults suffering from traumatic pain in the out-of-hospital environment.
Methods
This was a multicentre, prospective, single-blinded, randomized noninferiority trial involving 11 French emergency medical services.
| Population: | Adult patients with out-of-hospital acute traumatic pain rated ≥5/10 with a verbal numerical rating scale. |
| Intervention(s): | Ketamine 20mg IV push over 2 min, then 10mg q5min PRN for pain >3/10. EMS physicians used clinical judgment to adjust dosing according to patient age and body size. |
| Comparison: | Morphine 2 mg (if >60kg) or 3mg (if ≥60kg) IV push q5min PRN for pain >3/10. |
| Outcome(s): | Between-group difference in mean change in pain score between before drug administration and 30 min later. Secondary outcomes included (1) difference in mean change in pain score between before drug administration and 15, 45, and 60 min later; (2) incidence of rescue medication; (3) change in vital signs at 15, 45, 60 min and ED admission; (4) incidence of adverse events; (5) need to withdraw study drug and use specific drugs to antagonize severe adverse events; and (6) total weight-based dose of study drug received during 30 min period. |
Results
The difference in mean change in pain score between the ketamine (-3.7; 95% CI -4.2 to -3.2) and morphine (-3.8; 95% CI -4.2 to -3.2) groups was 0.1 (95% CI -0.7 to 0.9) demonstrating non-inferiority (threshold margin <1.3). The incidence of adverse events in the ketamine group and morphine groups were 40.8% (95% CI 32.0 to 49.6%) and 16.8% (95% CI 10.4 to 25.0%), respectively (RD 24.0%; 95% CI 12.8 to 35.2%). Emergence phenomenon was the most common adverse event in the ketamine group (20%; 95% CI 12.8 to 27.2%). Nausea was the most common adverse event in the morphine group (10.6%; 95% CI 2.9 to 16.3%).
Authors’ Conclusions
“In the KETAMORPH study of patients with out-of-hospital traumatic pain, the use of intravenous ketamine compared with morphine showed non-inferiority for pain reduction. In the ongoing opioid crisis, ketamine administered alone is an alternative to opioids in adults with out-of-hospital traumatic pain.”
Limitations
This study was single-blinded and conducted in an EMS system where an emergency physician is providing direct patient care with at least a nurse in a mobile intensive care unit. Additionally, the starting morphine dose used were relatively low.
Bottom Line
Ketamine is non-inferior to morphine for the reduction of acute traumatic pain in out-of-hospital environment. However, there were important differences in adverse event rate, notably an elevated risk of emergence phenomenon associated with ketamine, that must be carefully considered when selecting analgesic options in a resource-limited prehospital setting.
Citation
Clément Le Cornec, Marion Le Pottier, Hélène Broch, et al. (29 Jan 2024): Ketamine Compared With Morphine for Out-Of-Hospital Analgesia for Patients With Traumatic Pain, JAMA Network Open, DOI: 10.1001/jamanetworkopen.2023.52844
Click HERE to read the original article.
Prehospital eFAST & HEMS Clinical Decision Making in Trauma
Background and Objectives
The extended focus assessment with sonography in trauma (eFAST) has demonstrated utility in the emergency department, particularly with respect to the early decision making around the management of pneumothorax, hemothorax, and hemoperitoneum. Previous studies have shown that implementing a prehospital point-of-care ultrasound (POCUS) program is feasible, but the evidence supporting its impact on clinical management is limited. This study sought to determine whether prehospital eFAST affected clinical care for trauma patients transported by a helicopter emergency medical service (HEMS) program.
Methods
This was a retrospective case series of all trauma patients transported by a US-based HEMS program using qualitative self report, chart review, and inter-rater reliability analysis.
| Population: | Adult patients with traumatic injury transported by helicopter from scene or inter-facility between Jan 1 2021 and Dec 31 2022 |
| Exposure/Intervention(s): | HEMS provider performed prehospital eFAST |
| Comparison: | N/A |
| Outcomes(s): | “Altered clinical care”, “had no effect on clinical care”, or “significantly increased confidence” but did not change care for decisions to (1) reposition an endotracheal tube, (2) withhold or perform needle thoracostomy, (3) alter location of needle thoracostomy, or (4) initiate or withhold transfusion of blood products. |
Results
Prehospital eFAST changed clinical care in 2.7% (95% CI 1.1 to 5.5%) of scene calls and 3% (95% CI 0.1 to 16%) of inter-facility calls. Changes were primarily preventing unnecessary needle thoracostomy and initiating transfusion of blood products. Prehospital eFAST increased provider confidence in clinical care but did not change management in 9.8% (95% CI 6.2 to 14.4%) of cases. Overall, there was moderate agreement of image interpretation between providers and QA physician (k 0.449; 95% CI 0.380 to 0.518). Excluding indeterminate scans, agreement was substantial ( 0.765; 95% CI 0.624 to 0.906).
Authors’ Conclusions
“In this two-year retrospective case series, eFAST exams performed by flight crew members were shown to alter clinical care in 2.7% of cases where ultrasound was performed and to increase provider confidence in decision making in an additional 8.5% of cases. The changes to care were primarily avoiding unnecessary needle thoracostomy and initiating blood products or TXA when vital signs were variable and the degree of hemorrhagic shock unclear.”
Limitations
This was a retrospective study conducted in a single HEMS program that relied on qualitative self-report and not blinded, abstracted QA chart review data. Prehospital eFAST was performed for less than half the patients meeting inclusion criteria.
Bottom Line
Time and resources permitting, eFAST may have a useful role in the prehospital management of trauma patients, however a robust training program for providers and image quality and interpretation QA process are required in addition to further research towards identifying which patients may benefit most.
Citation
Benjamin Smith, Daniel Willner, & William Roper (4 Mar 2024): Prehospital Extended FAST Exams Improve Clinical Decision Making by Helicopter EMS Crews, Prehospital Emergency Care, DOI: 10.1080/10903127.2024.2320746
Click HERE to read the original article.
