Provision of Out-of-hospital Analgesia to Older Fallers With Suspected Fractures: Above Par, but Opportunities for Improvement Exist

Academic Emergency Medicine. Volume 20, Issue 8, pages 761–768, August 2013

Pre-hospital Research Forum

Objectives
Paramedics frequently attend older patients who have fallen and sustained suspected fractures, a population of patients who may be at risk of inadequate analgesic care. This prospective study aimed to describe the rate and effectiveness of analgesia administered by paramedics to older patients with suspected fractures secondary to falls and to identify predictive factors associated with provision of analgesia.

Methods

A cohort of older patients aged greater than 65 years with suspected fall-related fractures was extracted from a database of 1,610 cases collected during a prospective, nonconsecutive observational study of older people who had fallen and received an ambulance response from October 1, 2010, through June 30, 2011. Fall-specific data, collected on scene by paramedics using a specially designed data form, were linked to patient clinical records and dispatch information. Descriptive analyses were performed to describe rates and effectiveness of analgesic administration, and multivariate logistic regression was conducted to identify factors associated with provision of analgesia.

Results
Of 1,610 patients in the observational study database, there were 333 patients identified as having suspected fractures, thus forming the study population. The mean (±SD) age was 82 (±8) years, and 75% were female. Suspected fractures of the hip were most common (42%). An initial pain score was recorded in 67% of cases, and the median initial pain severity was 8 of 10. Overall, 60% received analgesia, and 80% of those received parenteral opiates. Intravenous (IV) morphine was most common (63%), followed by methoxyflurane (39%) and intranasal fentanyl (17%). Administration of oral analgesics was uncommon. Analgesia was considered to be clinically effective (≥30% relative reduction in pain severity) in 62% of cases. Patients with suspected hip fractures had greater odds of receiving analgesia compared to those with suspected fractures at other anatomical sites. Compared to those with mild pain, the odds of receiving analgesia increased significantly for patients with moderate pain and severe pain.

Conclusions
In this population of older people who fell and sustained suspected fractures, two-thirds received paramedic-administered analgesia. The majority of patients received clinically effective analgesia, and the presence of a suspected hip fracture increased the likelihood of receiving pain relief.

http://onlinelibrary.wiley.com/doi/10.1111/acem.12190/abstract

Assessment of the Addition of Prehospital Continuous Positive Airway Pressure (CPAP) to an Urban Emergency Medical Services (EMS) System in Persons with Severe Respiratory Distress

The Journal of Emergency Medicine. Volume 45, Issue 2 , Pages 210-219, August 2013

© Gary Wilson/ Pre-hospital Research Forum

The use of continuous positive airway pressure (CPAP)-assisted ventilation in the prehospital setting has not been well studied.

Objectives
The purpose of this study was to measure the efficacy of adding prehospital CPAP to an urban emergency medical services (EMS) respiratory distress protocol for persons with respiratory distress.

Methods
An historical cohort analysis of consecutive EMS patients presenting during the years 2005–2010. Groups were matched for severity of respiratory distress. Physiologic variables were the primary outcomes obtained from first responders and upon triage in the Emergency Department. Additional outcomes included endotracheal intubation rate, hospital mortality, overall hospital length of stay (LOS), intensive care unit (ICU) admission, and ICU LOS.

Results
There were a total of 410 consecutive patients with predetermined criteria for severe respiratory distress, 235 historical controls matched with 175 post-implementation patients, entered in the study. The average age was 67 years; 54% were men. There were significant median differences in heart and respiratory rates favoring the historical cohort (all p < 0.05). There were no significant differences in intubation rate, overall hospital LOS, ICU admission rate, ICU LOS, or hospital mortality (all p > 0.05). Patients who were continued on non-invasive ventilatory assistance had a significantly improved rate of intubation and ICU LOS (all p < 0.05).

Conclusion
The addition of CPAP to an EMS prehospital respiratory distress protocol resulted in improved heart and respiratory rates. Though not statistically significant, decrease in overall and ICU LOS were observed. Patients with continued ventilatory assistance seemed to have improved rates of intubation and ICU LOS.

http://www.jem-journal.com/article/S0736-4679(13)00332-6/abstract?elsca1=etoc&elsca2=email&elsca3=0736-4679_201308_45_2&elsca4=emergency_medicine

Plastic Bags for Prevention of Hypothermia in Preterm and Low Birth Weight Infants

Pediatrics. Published online June 3, 2013

© Gary Wilson/ Pre-hospital Research Forum

While the study was conducted within a hospital, the results could help to suggest that pre-hospital maternity kits contain at least one plastic bag.

BACKGROUND AND OBJECTIVES: Hypothermia contributes to neonatal mortality and morbidity, especially in preterm and low birth weight infants in developing countries. Plastic bags covering the trunk and extremities of very low birth weight infants reduces hypothermia. This technique has not been studied in larger infants or in many resource-limited settings. The objective was to determine if placing preterm and low birth weight infants inside a plastic bag at birth maintains normothermia.

METHODS: Infants at 26 to 36 weeks’ gestational age and/or with a birth weight of 1000 to 2500 g born at the University Teaching Hospital in Lusaka, Zambia, were randomized by using a 1:1 allocation and parallel design to standard thermoregulation (blanket or radiant warmer) care or to standard thermoregulation care plus placement inside a plastic bag at birth. The primary outcome measure was axillary temperature in the World Health Organization–defined normal range (36.5–37.5°C) at 1 hour after birth.

RESULTS: A total of 104 infants were randomized. At 1 hour after birth, infants randomized to plastic bag (n = 49) were more likely to have a temperature in the normal range as compared with infants in the standard thermoregulation care group (n = 55; 59.2% vs 32.7%; relative risk 1.81; 95% confidence interval 1.16–2.81; P = .007). The temperature at 1 hour after birth in the infants randomized to plastic bag was 36.5 ± 0.5°C compared with 36.1 ± 0.6°C in standard care infants (P < .001). Hyperthermia (>38.0°C) did not occur in any infant.

CONCLUSIONS: Placement of preterm/low birth weight infants inside a plastic bag at birth compared with standard thermoregulation care reduced hypothermia without resulting in hyperthermia, and is a low-cost, low-technology tool for resource-limited settings.

http://pediatrics.aappublications.org/content/early/2013/05/29/peds.2012-2030.abstract?papetoc