Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomised controlled trial.

INTRODUCTION: Improved early pain control may affect the longer-term prevalence of persistent pain. In a previous randomised, controlled trial, we found that the administration of ketamine on hospital arrival decreased pain scores to a greater extent than morphine alone in patients with prehospital traumatic pain. In this follow-up study, we sought to determine the prevalence of persistent pain and whether there were differences in patients who received ketamine or morphine. METHODS: This study was a long-term follow-up study of the prehospital, prospective, randomised, controlled, open-label study comparing ketamine with morphine in patients with trauma and a verbal pain score of >5 after 5 mg intravenous morphine. Patients were followed-up by telephone 6-12 months after enrollment, and a questionnaire including the SF-36 (V.2) health-related quality of life survey and the Verbal Numerical Rating Scale for pain was administered. RESULTS: A total of 97/135 (72%) patients were able to be followed-up 6-12 months after enrollment between July 2008 and July 2010. Overall, 44/97 (45%) participants reported persistent pain related to their injury, with 3/97 (3%) reporting persistent severe pain. The prevalence of persistent pain was the same between study groups (22/50 (44%) for the ketamine group vs 22/47 (46%) for the morphine group). There was no difference in the SF-36 scores between study arms. CONCLUSIONS: There is a high incidence of persistent pain after traumatic injury, even in patients with relatively minor severity of injury. Although decreased pain scores at hospital arrival are achieved with ketamine compared with morphine, this difference does not affect the prevalence of persistent pain or health-related quality of life 6 months after injury. Further larger studies are required to confirm this finding. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry (ACTRN12607000441415).

Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial.

STUDY OBJECTIVE: We assess the efficacy of intravenous ketamine compared with intravenous morphine in reducing pain in adults with significant out-of-hospital traumatic pain. METHODS: This study was an out-of-hospital, prospective, randomized, controlled, open-label study. Patients with trauma and a verbal pain score of greater than 5 after 5 mg intravenous morphine were eligible for enrollment. Patients allocated to the ketamine group received a bolus of 10 or 20 mg, followed by 10 mg every 3 minutes thereafter. Patients allocated to the morphine alone group received 5 mg intravenously every 5 minutes until pain free. Pain scores were measured at baseline and at hospital arrival. RESULTS: A total of 135 patients were enrolled between December 2007 and July 2010. There were no differences between the groups at baseline. After the initial 5-mg dose of intravenous morphine, patients allocated to ketamine received a mean of 40.6 mg (SD 25 mg) of ketamine. Patients allocated to morphine alone received a mean of 14.4 mg (SD 9.4 mg) of morphine. The mean pain score change was -5.6 (95% confidence interval [CI] -6.2 to -5.0) in the ketamine group compared with -3.2 (95% CI -3.7 to -2.7) in the morphine group. The difference in mean pain score change was -2.4 (95% CI -3.2 to -1.6) points. The intravenous morphine group had 9 of 65 (14%; 95% CI 6% to 25%) adverse effects reported (most commonly nausea [6/65; 9%]) compared with 27 of 70 (39%; 95% CI 27% to 51%) in the ketamine group (most commonly disorientation [8/70; 11%]). CONCLUSION: Intravenous morphine plus ketamine for out-of-hospital adult trauma patients provides analgesia superior to that of intravenous morphine alone but was associated with an increase in the rate of minor adverse effects.

Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*.

OBJECTIVE: To evaluate the effects on temperature and outcome at hospital discharge of a pre-hospital rapid infusion of large volume, ice-cold intravenous Hartmann's solution in patients with out-of-hospital cardiac arrest and an initial cardiac rhythm of asystole or pulseless electrical activity. DESIGN: Prospective, randomized, controlled clinical trial. SETTING: Pre-hospital emergency medical service and 12 critical care units in Melbourne, Australia. PATIENTS: One hundred and sixty three patients who had been resuscitated from cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity. INTERVENTIONS: : Patients were randomized to either pre-hospital cooling using a rapid infusion of up to two litres ice-cold Hartmann's solution (82 patients) or cooling after hospital admission (81 patients). The planned duration of therapeutic hypothermia (32 °C-34 °C) in both groups was 24 hrs. MEASUREMENTS AND MAIN RESULTS: Patients allocated to pre-hospital cooling received a median of 1500 ml of ice-cold fluid. This resulted in a mean decrease in core temperature of 1.4 °C compared with 0.2 °C in hospital cooled patients (p < .001). The time to therapeutic hypothermia (<34 °C) was 3.2 hrs in the pre-hospital cooled group compared with 4.8 hrs in the hospital cooled group (p = .0328). Both groups received a mean of 15 hrs cooling in the hospital and only 7 patients in each group were cooled for 24 hrs. Overall, there was no difference in outcomes at hospital discharge with favorable outcome (discharge from hospital to home or rehabilitation) in 10 of 82 (12%) in the pre-hospital cooled patients, compared with 7 of 81 (9%) in the hospital cooled patients (p = .50). In the patients with a cardiac cause of the arrest, 8 of 47 patients (17%) who received pre-hospital cooling had a favorable outcome at hospital discharge compared with 3 of 43 (7%) in the hospital cooled group (p = .146). CONCLUSIONS: In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity, pre-hospital cooling using a rapid infusion of large-volume, ice cold intravenous Hartmann's solution decreases core temperature at hospital arrival and decreases the time to therapeutic hypothermia. In patients with a cardiac cause of the arrest, this treatment may increase the rate of favorable outcome at hospital discharge. Further larger studies should evaluate the effects of pre-hospital cooling when the initial cardiac rhythm is asystole or pulseless electrical activity, particularly in patients with a cardiac cause of the arrest.

Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.

OBJECTIVE: To determine whether paramedic rapid sequence intubation in patients with severe traumatic brain injury (TBI) improves neurologic outcomes at 6 months compared with intubation in the hospital. BACKGROUND: Severe TBI is associated with a high rate of mortality and long-term morbidity. Comatose patients with TBI routinely undergo endo-tracheal intubation to protect the airway, prevent hypoxia, and control ventilation. In many places, paramedics perform intubation prior to hospital arrival. However, it is unknown whether this approach improves outcomes. METHODS: In a prospective, randomized, controlled trial, we assigned adults with severe TBI in an urban setting to either prehospital rapid sequence intubation by paramedics or transport to a hospital emergency department for intubation by physicians. The primary outcome measure was the median extended Glasgow Outcome Scale (GOSe) score at 6 months. Secondary end-points were favorable versus unfavorable outcome at 6 months, length of intensive care and hospital stay, and survival to hospital discharge. RESULTS: A total of 312 patients with severe TBI were randomly assigned to paramedic rapid sequence intubation or hospital intubation. The success rate for paramedic intubation was 97%. At 6 months, the median GOSe score was 5 (interquartile range, 1-6) in patients intubated by paramedics compared with 3 (interquartile range, 1-6) in the patients intubated at hospital (P = 0.28).The proportion of patients with favorable outcome (GOSe, 5-8) was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) in the hospital intubation group (risk ratio, 1.28; 95% confidence interval, 1.00-1.64; P = 0.046). There were no differences in intensive care or hospital length of stay, or in survival to hospital discharge. CONCLUSIONS: In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.

Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial.

BACKGROUND: Therapeutic hypothermia is recommended for the treatment of neurological injury after resuscitation from out-of-hospital cardiac arrest. Laboratory studies have suggested that earlier cooling may be associated with improved neurological outcomes. We hypothesized that induction of therapeutic hypothermia by paramedics before hospital arrival would improve outcome. METHODS AND RESULTS: In a prospective, randomized controlled trial, we assigned adults who had been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation to either prehospital cooling with a rapid infusion of 2 L of ice-cold lactated Ringer's solution or cooling after hospital admission. The primary outcome measure was functional status at hospital discharge, with a favorable outcome defined as discharge either to home or to a rehabilitation facility. A total of 234 patients were randomly assigned to either paramedic cooling (118 patients) or hospital cooling (116 patients). Patients allocated to paramedic cooling received a median of 1900 mL (first quartile 1000 mL, third quartile 2000 mL) of ice-cold fluid. This resulted in a mean decrease in core temperature of 0.8 degrees C (P=0.01). In the paramedic-cooled group, 47.5% patients had a favorable outcome at hospital discharge compared with 52.6% in the hospital-cooled group (risk ratio 0.90, 95% confidence interval 0.70 to 1.17, P=0.43). CONCLUSIONS: In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation, paramedic cooling with a rapid infusion of large-volume, ice-cold intravenous fluid decreased core temperature at hospital arrival but was not shown to improve outcome at hospital discharge compared with cooling commenced in the hospital.

Prehospital noninvasive ventilation: a viable treatment option in the urban setting.

OBJECTIVE: To determine the viability of prehospital noninvasive ventilation (NIV) as a prelude to a definitive clinical trial. METHODS: This was a retrospective observational study of patients (aged > 55 years, severe shortness of breath) transported to a tertiary emergency department (10/5/03-12/28/04). Data were extracted from paramedic and hospital medical records. The primary outcome measure was the number of patients who could potentially benefit from prehospital NIV. They were defined as "conscious upon paramedic arrival and who required ventilatory support (bag/valve/mask ventilation [BVM], NIV or endotracheal intubation) during transport or within 30 minutes of arrival at the emergency department (ED)." The secondary outcome measures were the effectiveness of existing paramedic treatment regimens and paramedic management times. RESULTS: Two hundred sixty-four patients were enrolled (mean age 75.5 +/- 8.7 years, 59.1% male). Sixty-seven patients (25.4%, 95% CI: 20.3-31.2) met the primary outcome measure: 31 (11.7%, 95% CI: 8.2-16.4) received prehospital BVM, an additional 35 (13.3%, 95% CI: 9.5-18.1) received NIV in the ED and one (0.4%, 95% CI: 0.0-2.4) was intubated in the ED. Prehospital treatment resulted in significant (p < 0.001) improvements in systolic blood pressure (151.2 dropping to 144.2 mmHg), respiratory rate (29.4 dropping to 26.3 breaths/minute), and oxygen saturation (92.3% rising to 96.2%). Median paramedic management time was 33 minutes (IQR 29-40). CONCLUSION: Prehospital treatment significantly improved patient vital signs. However, a considerable proportion of patients still required ventilatory support either prehospital or early in their ED course. Further research is indicated to determine if these patients would benefit from prehospital NIV.