Factors associated with unoffered trauma analgesia in critical care transport.

OBJECTIVE: Pain relief is a key out-of-hospital patient care outcome measure, yet many trauma patients do not receive prompt analgesia. Although specialty critical care transport (CCT) teams provide analgesia frequently, successfully, and safely, there is still a population of CCT patients to whom analgesia is not offered. We report the factors associated with non-administration of analgesia and with analgesic effect in trauma patients cared for by CCT teams. METHODS: This is a retrospective review of consecutive transport records for nonintubated trauma patients with self-reported pain during specialty CCT care. Patient demographics, CCT interventions, clinical traits, and pain self-reports are measured. Means comparisons are made with a univariate analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) are reported for between-group comparisons. RESULTS: Of the 209 enrolled patients, 169 (80.9%; 95% CI, 75.6%-86.2%) were treated (147 received analgesia and 22 offered analgesia but refused). In patients with pain scale documentation (n=145), self-reported pain on a scale from 0 to 10 decreased from 6.8+/-2.8 to 3.3+/-2.4 (P

Sedative use in patients receiving neuromuscular blocking agents from a helicopter flight team.

INTRODUCTION: Cognitive awareness under general anesthetic may occur in up to 0.2% of patients, with approximately twice the risk in chemically paralyzed patients. Patients in emergency and critical care areas frequently receive neuromuscular blocking agents (NMBA), but a recent survey indicated that only 90% to 96% of critical care nurses routinely provide concurrent sedative medications to those patients. We sought to determine the potential for awake paralysis in patients transported by helicopter critical care transport teams and to evaluate for associations with clinical factors. METHODS: A retrospective review was performed of the rotor-wing transport records of 103 consecutive patients receiving NMBAs and without cardiac arrest during their care. Using hospital-approved pharmacological references, independent reviewers determined whether individual patients were likely to be under the effects of sedative medications during their period of neuromuscular blockade. Descriptive statistics are reported, and the chi-square test was used to evaluate relationships. RESULTS: The sample population was 70.9% male, 89.3% adult, 53.4% trauma/surgical, 66% interhospital, and 88.3% normotensive (SBP>90 mm Hg). Clinically, 91.3% of patients were judged as probably to have been under the effects of some sedative during their period of paralysis. There was not a significant association between the use of sedatives and any of the factors studied: sex, age, diagnosis, site of origin, flight nurse experience, or systolic blood pressure. Patients most commonly received benzodiazepine alone (70.2%), followed by benzodiazepine+opioid (23.4%), opioid alone (5.3%), and propofol (1.1%). Medication choice was also unrelated to any of the clinical factors studied. DISCUSSION: Awake paralysis is difficult to detect but is a serious practice complication. In anesthesia practice, 96% of such cases were considered substandard care, even with prompt recognition and management. Flight nurses administer sedatives at rates similar to other critical care nurses but not to all chemically paralyzed patients. We were unable to identify clinical correlations with medication use or omission. Additional phenomenological and quantifiable evaluations of consciousness during the transport of chemically paralyzed patients would be valuable studies. CONCLUSION: Patients receiving NMBAs during transport by helicopter flight teams are at risk for awareness during paralysis. Both practice development and research efforts in this area would be useful.

Efficacy of fentanyl analgesia for trauma in critical care transport.

INTRODUCTION: Pain relief is one of the most important interventions for out-of-hospital patient care providers. This paper documents the need for and benefits from the administration of fentanyl to trauma patients during critical care transport. METHODS: We underwent a retrospective review of the transport charts of 100 trauma patients who received fentanyl analgesia during transport and who were able to use a numeric response scale to rate their pain from 0 to 10. RESULTS: Mean initial pain report was 7.6 +/- 2.2 units, relieved to 3.7 +/- 2.8 units by a mean total fentanyl dose of 1.6 +/- 0.8 microg/kg (P < .001). Neither initial pain level nor pain relief differed between male and female patients, but did differ between patients originating at the site of injury and those transferred between hospitals. Fentanyl dose correlated poorly with the magnitude of pain relief (r = 0.22), but a dose greater than 2 microg/kg provided more relief than lower doses (5.1 +/- 2.1 vs 3.6 +/- 2.4, P < .02). CONCLUSION: Fentanyl analgesia from these critical care transport teams provided significant pain relief to trauma patients. Pain reduction was greater for patients who received more than 2.0 microg/kg of fentanyl.

EMS certification requirements for flight nurses.

INTRODUCTION: Emergency medical technician (EMT) or paramedic (EMTP) certification requirements for flight nurses (FNs) providing on-scene patient care vary. We surveyed those requirements and evaluated the relationships between flight team composition or program location and FN EMS certification. METHODS: Telephone survey of all 184 rotor-wing programs responding with a nurse to scenes RESULTS: The overall EMS training requirement for FNs was: none-57.6%, EMT-21.7%, EMTP-14.7%, local credential (not EMT or EMTP)-6.0%. Second team members were EMTP, RN, physician, or respiratory therapist (RRT). Overall, team configuration related significantly to FN EMS certification (P =.01). FN/EMTP and FN/RRT teams were individually significant (P <.01), with FN/EMTP teams tending not to require certification and all FN/RRT teams tending toward a certification requirement. Neither FN/FN nor FN/physician pairings related significantly with FN EMS certification requirements. Regional patterns emerged to both crew configuration and FN EMS certification requirements. CONCLUSION: Most flight programs do not require FN EMT/EMTP certification. Team configuration and geography are related to those requirements.