[Prehospital analgesia performed by paramedics: quality in processes and effects under medical supervision]

D Häske, B Schempf, G Gaier, C Niederberger
Der Anaesthesist 2014, 63 (3): 209-16

BACKGROUND: In the context of the new education program for German paramedics, a discussion has been fueled regarding the emergency care competencies of paramedics. In 1999 a system for training and qualification of paramedics was established in the emergency medical service (EMS) area of Reutlingen (Germany), including an algorithm for analgesia using ketamine and midazolam. Under defined circumstances analgesia may be administered to patients in the absence of a physician.

AIM: The objectives of the study were to evaluate the effectiveness of pain reduction measured by a recognized assessment scale and the safety of analgesia with ketamine and midazolam administered by paramedics. This study specifically focused on the medical results and associated processes and not on the legal aspects.

MATERIALS AND METHODS: In a retrospective analysis analgesia performed by paramedics who had undergone standardized training with annual controls and under medical supervision was investigated with regard to administration processes and efficacy. Analysis endpoints included vital signs at baseline and on transfer to the emergency department, pain score as defined by a numeric rating scale (NRS 0-10), the amount of ketamine administered and the occurrence of side effects (e.g. respiratory and circulatory disorders, nausea, qualitative and quantitative disturbance of consciousness).

RESULTS: A total of 528 instances of analgesia performed by paramedics were registered. The average patient age was 48 ± 23 years (range 5-95 years). Trauma to the extremities was the most common indication for the administration of analgesia with 48 % and 38 % attributable to the upper and lower extremities, respectively. Serious complications were not observed. Administration of analgesia resulted in a highly significant reduction in pain scores (NRS p<0.0001). Mean initial pain score was 8 with an interquartile range (IQR) of 7-8 and a 95% confidence interval (95% CI) of 7.5-7.9 which was decreased to 3 (IQR 2-3, 95% CI 2.2-2.7) on transfer to the emergency department. The number of patients with a pain score of NRS ≤4 in the emergency department was 96 % (n=506). All other vital signs were essentially unchanged and the rate of side effects was low (2.8 %). Potentially life-threatening complications were not reported. The mean midazolam dosage administered was 1 ± 0.4 mg and the mean dosage of ketamine was 27 ± 12 mg. The investigation was limited by restricted documentation and patients who were not treated with analgesics were not included in the study.

CONCLUSION: After appropriate training and regular control analgesia administered by paramedics in the present system was safely and effectively applied.

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