Pain management for casualties receiving lifesaving interventions in the prehospital scenario: Raising awareness of our human nature.

BACKGROUND: Lifesaving interventions (LSIs) are the hallmark of medical care in trauma casualties, reducing mortality and morbidity. Analgesia is another essential treatment, which has been shown to improve outcomes and decrease long-term complications. However, oligoanalgesia is common, and information regarding its relation to the performance of LSIs is scarce. The purpose of this study was to assess the relation between the performance of LSIs and analgesia administration in the prehospital environment. METHODS: A retrospective database-based study was performed, including all trauma casualties treated by Israeli Defense Forces physicians and paramedics during 2006 to 2017 and admitted to hospitals participating in the Israeli National Trauma Registry. Included LSIs were tourniquet application, administration of tranexamic acid and freeze-dried plasma, and administration of chest decompression. Casualties treated with endotracheal intubation or cricothyroidotomy were excluded. RESULTS: In the multivariable logistic regression analysis, LSIs were associated with prehospital analgesia administration (odds ratio [OR], 3.59; confidence interval [CI], 2.56-5.08; p < 0.001). When assessing for the different LSIs, tourniquet application (OR, 2.83; CI, 1.89-4.27; p < 0.001) and tranexamic acid administration (OR, 4.307; CI, 2.42-8.04; p < 0.001) were associated with prehospital analgesia administration. CONCLUSION: A positive association exists between performance of LSIs and administration of analgesia in the prehospital environment. Possible explanations may include cognitive and emotional biases affecting casualty care providers. LEVEL OF EVIDENCE: Retrospective study, level IV.

Trends in prehospital pain management following the introduction of new clinical practice guidelines.

BACKGROUND: Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF. METHODS: All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided. RESULT: Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6-16%, p < 0.001). CONCLUSION: Pain management has become more common in trauma patients' prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Comparison of Patients Undergoing Tracheostomy in the Intensive Care Unit versus in the Wards.

BACKGROUND: In Israel, critically ill patients are ventilated and managed in intensive care units or general wards. OBJECTIVES: To compare the mortality rates and long-term cognitive and functional outcomes of ventilated patients who underwent tracheostomy insertion in the Medical ICU (MICU) versus those cared for in the in-patient wards. METHODS: The study comprised 170 patients who underwent percutaneous dilatational tracheostomy (PDT) over an 18-month period in the MICU (n=102) and in in-patient wards (internal medicine and neurology) (n=68). Telephone interviews were conducted with living patients and/or their relatives at least 6 months after discharge from the hospital. RESULTS: Ward patients were 10 years older than ICU patients undergoing PDT (P = 0.003). The length of stay (LOS) in the wards was longer than in the ICU (P < 0.001), whereas the total LOS in the hospital was similar (P = 0.43). ICU mortality was lower than in the wards (P = 0.001) but hospital mortality was comparable between the two groups (P = 0.17). At 6 months follow-up more ICU patients were fully conscious, weaned from ventilation, and decannulated. More patients in the ICU group were at home and were independent or had mildly impaired activities of daily living. More patients in the ward group were residing in long-term care facilities with functional limitations. CONCLUSIONS: MICU patients who undergo tracheostomy may have a good long-term functional and cognitive outcome. More studies are needed to further assess long-term outcomes in these patients.