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Bloc ilio-fascial: Docteur ou IDE, Faites en !

Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review.



Femoral fractures are painful injuries frequently encountered by prehospital practitioners. Systemic opioids are commonly used to manage the pain after a femoral fracture; however, regional techniques for providing analgesia may provide superior targeted pain relief and reduce opioid requirements. Fascia Iliaca Compartment Block (FICB) has been described as inexpensive and does not require special skills or equipment to perform, giving it the potential to be a suitable prehospital intervention. ProblemThe purpose of this systematic review is to summarize published evidence on the prehospital use of FICB in patients of any age suffering femoral fractures; in particular, to investigate the effects of a prehospital FICB on pain scores and patient satisfaction, and to assess the feasibility and safety of a prehospital FICB, including the success rates, any delays to scene time, and any documented adverse effects.


A literature search of MEDLINE/PubMED, Embase, OVID, Scopus, the Cochrane Database, and Web of Science was conducted from January 1, 1989 through February 1, 2017. In addition, reference lists of review articles were reviewed and the contents pages of the British Journal of Anaesthesia (The Royal College of Anaesthetists [London, UK]; The College of Anaesthetists of Ireland [Dublin, Ireland]; and The Hong Kong College of Anaesthesiologists [Aberdeen, Hong Kong]) 2016 along with the journal Prehospital Emergency Care (National Association of Emergency Medical Service Physicians [Overland Park, Kansas USA]; National Association of State Emergency Medical Service Officials [Falls Church, Virginia USA]; National Association of Emergency Medical Service Educators [Pittsburgh, Pennsylvania USA]; and the National Association of Emergency Medical Technicians [Clinton, Mississippi USA]) 2016 were hand searched. Each study was evaluated for its quality and its validity and was assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine (OCEBM; Oxford, UK).


Seven studies involving 699 patients were included (one randomized controlled trial [RCT], four prospective observational studies, one retrospective observational study, and one case report). Pain scores reduced after prehospital FICB across all studies, and some achieved a level of significance to support this. Out of a total of 254 prehospital FICBs, there was a success rate of 90% and only one adverse effect reported.


"Across all studies, a total of 256 FICBs were performed in a prehospital environment by a variety of practitioners (145 by physicians, 100 by nurses, and 11 by paramedics)"


Few studies have investigated the effects of prehospital FICB on patient satisfaction or scene time delays.


The FICB is suitable for use in the prehospital environment for the management of femoral fractures. It has few adverse effects and can be performed with a high success rate by practitioners of any background. Studies suggest that FICB is a useful analgesic technique, although further research is required to investigate its effectiveness compared to systemic opioids..


Penthrox: Ne nous emballons pas

Methoxyflurane in Pre-Hospital Settings: A Review of Clinical Effectiveness, Cost-Effectiveness and Guidelines


Beaucoup d'intérêt pour cet agent  tombé en désuétude en anesthéise du fait d'effets secondaires importants  mais utilisé comme antalgique. La HAS a émis un avis pour le moin mitigé. C'est également la position de l'agence du médicament canadienne qui reconnait des effets antalgiques réel mais sans avantage vrai par rapport à la morphine dans le domaine pré-hospitalier.



The objective of this review is to evaluate the clinical effectiveness, cost-effectiveness, and evidence-based guidelines for the use of low-dose methoxyflurane for the management of moderate to severe pain associated with trauma or procedures in the pre-hospital setting.


Methoxyflurane en altitude ? Mais oui

WIlkes M et Al. Wilderness Environ Med. 2018 Sep;29(3):388-391.

Methoxyflurane is a volatile, fluorinated anesthetic agent with analgesic properties. Although no longer used as an anesthetic due to concerns regarding renal toxicity in high doses, it has enjoyed a resurgence as an inhaled analgesic in prehospital care and in the emergency department. The agent is nonflammable and leads to rapid, titratable analgesia without intravenous access. The Penthrox inhaler device is light, robust, and straightforward to administer. Consequently, it has been proposed as an ideal analgesic for the remote high altitude setting.

MethoxyF en montagne.jpg

We report its use for procedural analgesia during suprapubic aspiration for acute urinary retention at a remote rescue post at night, in cold winter conditions, at 4470 m altitude in Machermo, Nepal. We found that methoxyflurane provided rapid, effective analgesia for our patient’s visceral and procedural pain. The inhaler was easy to administer, and the patient remained responsive to voice, with satisfactory oxygen saturation and respiratory rate throughout. We also briefly review the administration, dosing, efficacy, and safety of methoxyflurane and its role in remote medical care.

Penthrox: A risque d'hyperthermie maligne ?

An in-vitro model of malignant hyperthermia: differential effects of inhalation anesthetics on caffeine-induced muscle contractures.

L'engouement en médecine d'urgence pour l'emploi du penthrox (1) se justifie notamment par sa simplicité de mise en oeuvre et la très grande rapidité d'obtention d'une analgésie qui reste cependant modérée (2). Cependant la HAS n'a pas retrouvé d'amélioration du service rendu pour cet agent d'anesthésie ancien. Dans les diverses publications, il n'est pratiquement jamais abordé le sujet du déclenchement d'une crise d'hyperthermie maligne. Pourtant cet agent est un agent déclencheur presqu'aussi "efficace" que l'halothane. Cette vieille publication l'atteste. Cceci étant dit il faut relativiser ce risque qui parait également dose dépendant sans que l'on sache bien à quel niveau se situe le seuil déclenchant (3) .

Clinical concentrations of anesthetics augment caffeine-induced contracture of frog sartorius muscle; however, anesthetics differ in this characteristic. The potentiation was quantitated using six paired sartorius muscles for each specified concentration of anesthetic and controls. At a concentration of 1 MAC, the greatest potentiation occurred with 2 mM caffeine for all anesthetics studied. Under these conditions the order of magnitude of augmentations was: chloroform (15 times); halothane (11 times); methoxyflurane (10 times); cyclopropane (5 times); enflurane (4 times); isoflurane (3 times); diethyl ether (2 times); Baxter 3224 (2 times); fluroxene (1.4 times); nitrous oxide (1.3 times).

HTMA Methoxy.jpeg

Halothane at .5 MAC augments the 2 mM caffeine-induced contracture almost seven times, and at 2 MAC almost 13 times, whereas 2 MAC isoflurane potentiates the caffeine-induced contracture only four times and 4 MAC diethyl ether only two and a half times. It is postulated that those anesthetics that most potentiate caffeine-induced contracture may be the most potent triggering agents of malignant hyperthermia.


Penthrox: Séduisant mais

Low-dose methoxyflurane analgesia in adolescent patients with moderate-to-severe trauma pain: a subgroup analysis of the STOP! study.

Il existe un engouement pour l''emploi du methoxyflurane pour la prise en charge de la douleur en urgence. Cela n'est pas surprenant pour cet anesthésique volatil connu depuis les années 1960. Il appartientt à la même classe pharmacologique que le sevoflurane/desflurane/isoflurane/halothane. Ses caractéristiques de solubilité dans le sang et les graisses n'en faisaient pas un bon agent d'induction d'anesthésie et son emploi prolongé était associé à une néphrotoxicité importante. Il partage avec ces derniers le même risque d'hyperthermie maligne. Néanmoins ces risques potentiels sont doses dépendants qu'il s'agisse de la nephrotoxicité (1) ou de l'hyperthermie maligne per-anesthésique (2) . Plus efficace qu'un mélange MEOPA (3), sa simplicité apparente de mise en oeuvre, la possibilité d'auto-administration et une action antalgique rapide sontà la based'un regain d'intérêt. Il fait l'objet d'un intense marketing dont la communauté médicale doit être consciente. De plus comme tous les agents d'anesthésie volatils, c'est un polluant environnemental. Certains militent pour des études plus conséquentes que celles actuellement disponibles (4, 5). Dans l'état actuel de la littérature son emploi à l'avant, aussi séduisant qu'il paraisse, doit être mûrement réfléchi, notamment pour la prise en charge des blessés qui saignent et qui présentent une plaie thoracique. On est loin là d'un emploi en SAU ou en préhospitalier civil (6) où l'usage du penthrox porte surtout sur de la traumatologie périphérique (7).


The undertreatment of acute pain presents a significant challenge in the Emergency Department. This post hoc subgroup analysis of a previously reported randomized controlled UK study reports the efficacy and safety of low-dose methoxyflurane analgesia in treating adolescent patients with moderate-to-severe trauma pain.

Patients and methods:

Three hundred patients (96 in the adolescent subgroup) aged ≥12 years requiring analgesia for acute trauma pain (pain score of 4-7 on the Numerical Rating Scale) at triage were randomized 1:1 to methoxyflurane (up to 6 mL) or placebo (normal saline), both administered using a Penthrox® inhaler. The patient could request rescue medication (paracetamol/opioids) at any time. The primary endpoint was the change from baseline in visual analog scale (VAS) pain intensity.


Mean VAS pain score for the adolescent subgroup at baseline was ~ 61 mm. Adjusted mean change in VAS pain intensity from baseline to 5, 10, 15, and 20 minutes was -24.5, -28.1, -31.6, and -31.7 mm for methoxyflurane and -14.6, -18.8, -19.2, and -23.7 mm for placebo, with a statistically significant treatment effect in favor of methoxyflurane overall across all four time points (-9.9 mm; 95% CI: -17.4, -2.4 mm; P=0.0104). Median time to first pain relief was significantly shorter with methoxyflurane (1 minute) than placebo (3 minutes, P<0.0001). Pain relief was reported within 1-10 inhalations in 95.7% of methoxyflurane-treated patients and 64.6% of placebo-treated patients. Rescue medication was requested by two (4.3%) methoxyflurane-treated patients and three (6.3%) placebo-treated patients. Over 95% of patients, physicians, and nurses rated methoxyflurane treatment as "Excellent", "Very Good" or "Good" compared with between 64% and 68% for placebo. The incidence of adverse events was higher with methoxyflurane (51%) than placebo (42%), mostly comprising mild/transient dizziness and headache.


This subgroup analysis shows that low-dose inhaled methoxyflurane is a rapid-acting and effective analgesic in adolescent patients presenting with moderate-to-severe trauma pain.

Penthrox: Avis de la HAS

logo-HAS-avis-antalgiqueL-120x80.jpgLe méthoxyflurane a été utilisé dès 1960 en Europe et aux États-Unis comme gaz anesthésiant halogéné à des doses plus élevées et avec des inhalateurs différents de ceux de PENTHROX. Il a été retiré du marché en 1974 compte tenu d’une faible utilisation en anesthésie. De plus, à fortes doses, le méthoxyflurane a été associé à une néphrotoxicité grave liée à la dose et à l’utilisation pendant de longues périodes au cours d’une anesthésie générale. Sous la dénomination PENTHROX liquide pour inhalation par vapeur en flacon de 3 ml, il est utilisé en Australie depuis 1993 et en Nouvelle Zélande depuis 2002 par les services d’urgence en tant qu’analgésique non opioïde, d’urgence. PENTHROX pourrait être une alternative aux antalgiques comme le MEOPA actuellement utilisés dans ces situations de traumatologie.

La spécialité PENTHROX dispose d’une AMM obtenue par procédure décentralisée dans 3 autres pays de l’union européenne en plus de la France : Belgique, Irlande, Royaume-Uni. Elle dispose d’une AMM en Australie depuis 1993 et en nouvelle Zélande depuis 2002 ; elle est commercialisée depuis ces dates dans ces 2 pays.


PENTHROX est une alternative aux antalgiques disponibles dans la prise en charge en urgence de la douleur modérée à sévère. Faute de données, il n’est pas possible de le situer par rapport aux alternatives antalgiques disponibles. Il présente un avantage pratique (pas de voie veineuse, auto-administration). Son principal inconvénient est la nécessité d’obtenir la coopération du patient, ce qui le contre-indique chez l’adulte inconscient ou au contraire agité. De plus, l’administration par voie inhalée limite son utilisation chez le patient présentant une insuffisance respiratoire chronique ou aiguë.

Les effets indésirables les plus fréquents rapportés avec PENTHROX ont été essentiellement les effets sur le système nerveux central tels que les vertiges, la somnolence et les céphalées. De rares cas d’hépatotoxicité ont été rapportés lors de l’utilisation du méthoxyflurane à dose antalgique.

Compte tenu des données cliniques disponibles versus placebo, PENTHROX apporte une réponse partielle au besoin thérapeutique dans le soulagement de la douleur en situation d’urgence. Il subsiste des incertitudes sur son efficacité dans les douleurs les plus sévères (EN>7). De plus, en l’absence de comparaison directe de qualité méthodologique satisfaisante, il n’est pas possible de le situer par rapport aux alternatives antalgiques disponibles. De ce fait, son impact sur la morbidité et sur la qualité de vie n’est à ce jour pas démontré. Par ailleurs, malgré sa praticité d’utilisation potentielle, son impact positif sur l’organisation des soins n’a pas été démontré.

Le service médical rendu est modéré. Compte tenu de :

– l’efficacité de PENTHROX démontrée versus placebo chez des patients ayant majoritairement une douleur d’intensité modérée,

– l’absence d’étude de qualité méthodologique suffisante l’ayant comparé aux autres antalgiques actuellement disponibles,

PENTHROX n’apporte pas d’amélioration du service médical rendu (ASMR V) par rapport aux autres antalgiques disponibles dans le soulagement d’urgence des douleurs modérées à sévères associées à un traumatisme chez des patients adultes conscients.


Penthrox: Peut-être MAIS l'hyperthermie maligne ?

Penthrox: a breath of PHEC air for the military?



Le penthrox est souvent présenté comme une nouveauté. Il s'agit d'un agent d'anesthésie ancien dont l'emploi a cessé du fait, entre autres,  d'une nephrotoxicité importante. Comme tous les agents anesthésiques halogénés, il possède une activité analgésique vraie. Il est aussi potentiellement  un agent déclenchant d'hyperthermie maligne anesthésique. Les auteurs font une présentation de ce produit en omettant d'aborder ce problème potentiel dont on sait qu'il touche (délai et doses déclenchantes) de manière diverse tous les halogénés (1)


Prehospital analgesia is vital to good clinical care and inhaled methoxyflurane (Penthrox) would be a valuable addition to the armed forces medical armoury. Penthrox would provide strong, fast-acting, self-administered and safe analgesia to patients with moderate to severe injuries. In addition, it would provide an option for strong analgesia which would not be subject to the regulations that govern controlled or accountable drugs which gives it a unique position as the military moves its focus from large enduring operations to small short-term training teams supported by lone combat medics in remote locations across the globe.


ALR en opex: 1 formation solide est nécessaire

Regional Anesthesia in the Combat Setting: Are ACGME Requirements Enough?

Dhanjal ST et Al. Mil Med. 2019 Feb 22. pii: usz007. doi: 10.1093/milmed/usz007


Il existe un grand engouement pour la réalisation d'ALR pour la prise en charge de la douleur des blessures de guerre. Ces techniques, dont certaines sont simples, nécessitent cependant un apprentissage dont la charge est probablement sous estimée. C'est ce qu'illustre ce travail pourtant effectué dans une population censée en maîtriser tous les aspects.



Updated Joint Trauma System Clinical Practice Guidelines (CPG) indicate regional anesthesia and pain management (RAAPM) are important for combat casualty care. However, it is unclear whether military anesthesiology residents are receiving adequate RAAPM training to meet the CPGs. The goal of this study was to conduct a preliminary evaluation of resident-completed combat-relevant regional anesthesia procedures. It was hypothesized that most residents would perform an adequate number of each procedure to presume proficiency.

Materials and Methods

Resident-performed, combat-relevant regional anesthesia procedure frequency was extracted from a database maintained at a military anesthesiology residency program. Data collection was limited to a 1-year period. Univariate statistics described procedure distributions, frequencies, and proportion of residents achieving pre-defined, empirically-supported experience criteria for each technique. Analyses examined proportional differences in meeting experience criteria by training-year.


Residents (N = 41) performed a variety of procedures. Simple procedures, such as saphenous peripheral nerve blocks, were performed at a greater frequency than more complicated procedures such as thoracic epidurals, continuous peripheral nerve blocks, and transverse abdominus plane blocks.


The majority of residents met experience criteria for four out of the eight measured combat-relevant blocks. There were no proportional differences in meeting procedural experience criteria across the different training levels.


These results suggest a possible gap between the needs of the Military Health System during conflict and current residency training experiences. Reasons for this gap, as well as solutions, are explored.




Morphine pour le blessé ? Un risque faible

Opioid analgesia on the battlefield: a retrospective review of data from Operation HERRICK.

Lewis P et Al. J R Army Med Corps. 2018 Sep;164(5):328-331.


Acute pain secondary to trauma is commonly encountered on the battlefield. The use of morphine to manage pain during combat has been well established since the 19th century. Despite this, there is relatively little research on analgesia use in this environment. This study aims to review the use and complications of morphine and other opioids during Operation HERRICK.


METHODS: A database search of the Joint Theatre Trauma Registry was completed looking for all incidences of morphine, fentanyl or naloxone use from February 2007 to September 2014. Microsoft Excel was used to analyse the results.


Opioid analgesia was administered to 5801 casualties. Morphine was administered 6742 times to 3808 patients. Fentanyl was administered 9672 times to 4318 patients. Naloxone was used 18 times on 14 patients, giving a complication rate of 0.24%. Opioid doses prior to naloxone administration range from 0 to 72 mg of morphine and from 0 to 100 mcg of fentanyl. Four casualties (two local civilians and two coalition forces) received naloxone despite no recorded opioids being administered. Opium abuse was prevalent among the local population in Afghanistan, and this could explain the rationale behind two local national casualties receiving naloxone without any documented opioids being given.


The use of opioids in a battlefield environment is extremely safe. Complication rates are similar to previously published data which is reassuring. The efficacy of different opioids was not covered by this study, and further analysis is required, particularly following the introduction of oral transmucosal fentanyl citrate and the availability of novel non-opioid analgesics.

| Tags : douleur


Penthrox ?: Franchement pas une nouveauté

A review of the safety and efficacy of inhaled methoxyflurane as an analgesic for outpatient procedures

C. Jephcott et Al. British Journal of Anaesthesia, ▪ (▪): 1e9 (2018)


Le méthoxyflurane (Penthrox) est un agent d'anesthésie halogéné, connu depuis les années 50 et tombé en désuétude à cause essentiellement de sa néphrotoxicité importante. Il semble être remis au goût du jour et est actuellement proposé pour des propriétés antalgiques qu'il partage avec tous les agents de sa classe pharmaceutique. Si son principe d'emploi apparaît intéressant, il existe des limites à son intérêt: Une technique d'inhalation à bien maîtriser, quelques effets secondaires notamment hypotension et somnolence, pas plus de 15 ml par semaine. Si son emploi sur de courtes durées permet de limiter le risque rénal, le risque d'hyperthermie maligne peranesthésique est toujours présent. Son efficacité serait équivalente à celle du meopa (1) et pour certains légèrement inférieure à celle de la morphine (2). La Commission de la transparence considère que la spécialité PENTHROX n’apporte pas d’amélioration du service médical rendu considéré comme modéré par rapport aux autres antalgiques disponibles (3) notamment pour les douleurs d'origine traumatique. Un médicament ancien remis au goût du jour mais qui cherche son positionnement (4). Son apport reste très discutable tout particulièrement sur les douleurs très sévères (à EVA >7).


Methoxyflurane delivered via a hand-held inhaler is a proven analgesic which has been used in Australasia for emergency relief of trauma associated pain since the 1970s. The agent is self-administered by the patient under the supervision of trained personnel. More than 5 million patients have received inhaled methoxyflurane without significant side effects. Methoxyflurane is also licensed in Australasia for the relief of pain in monitored conscious patients requiring analgesia for minor surgical procedures. Recent clinical studies undertaken in a variety of outpatient settings, including colonoscopy, prostate biopsy, dental procedures, bone marrow biopsy, and the management of burns dressings, indicate that inhaled methoxyflurane has significant analgesic activity, without producing deep sedation or respiratory depression. Return to full psychomotor activity is rapid. Thus, methoxyflurane may be a suitable and well-tolerated alternative to traditional i.v. sedative agents for outpatient medical and surgical procedures. There are direct advantages to the patient in terms of rapid recovery and an early return to normal activities, and significant benefits for outpatient departments in terms of cost saving and rate of throughput. Further randomised controlled trials comparing the efficacy, safety, and cost-effectiveness of inhaled methoxyflurane against traditional i.v. sedative techniques are currently in progress.


Douleur: On doit mieux faire

Battlefield pain management: A view of 17 years in Israel Defense Forces.

Benov A et Al J Trauma Acute Care Surg. 2017 Apr 5. doi: 10.1097/TA.0000000000001481. 
Quasiment aucun blessé ne reçoit un traitement antalgique sur son lieu de blessure ! Néanmoins les choses s'améliorent avec le temps. Dans l'expérience israélienne la morphine IV est l'antalgique le plus utilisé mais cela changé.



Pain control in trauma is an integral part of treatment in combat casualty care (CCC). More soldiers injured on the battlefield will need analgesics for pain than those who will need life-saving interventions (LSI). It has been shown that early treatment of pain improves outcomes after traumatic injury, while inadequate treatment leads to higher rates of PTSD. The purpose of this article is to report the Israel Defense Forces Medical Corps (IDF-MC) experience with point of injury (POI) use of analgesia.


All cases documented in the IDF Trauma Registry (ITR) between January 1997 and December 2014 were examined. All cases of POI pain medications were extracted. Data collection included mechanism of injury, wound distribution, pain medication administered, mortality, and provider type.


Of 8,576 patients, 1,056 (12.3%) patients who had at least one documented pain management treatment were included in this study. Demographics of the study population included 94.2% male and 5.8% female with a median age of 21 years. Injury mechanisms included 40.3% blast injuries (n=426) and 29% gunshot injuries (306). Of 1,513 injured body regions reported, 52% (787) were extremity wounds (upper and lower), 23% (353) were truncal wounds, and 17.7% (268) were head and neck injuries.

Douluer IDF.jpg

A total of 1,469 episodes of analgesic treatment were reported. The most common types of analgesics were morphine (74.7%, 1097 episodes), ketamine (9.6%, 141 episodes) and fentanyl (13.6%, 200 episodes).


Of the patients, 39% (413) received more than one type of analgesic. In 90.5% of cases, analgesia was administered by a physician or a paramedic. Over the span of the study period (1997-2014), types of analgesics given by providers at POI had changed, as fentanyl was introduced to providers. A total of 801 LSIs were performed on 379 patients (35.9%) receiving analgesia and no adverse events were found in any of the casualties.


Most casualties at POI did not receive any analgesics while on the battlefield. The most common analgesics administered at POI were opioids and the most common route of administration was intravenously (IV). This study provides evidence that over time analgesic administration has gained acceptance and has been more common place on the battlefield. Increasingly, more casualties are receiving pain management treatment early in CCC along with LSIs. We hope that this shift will impact CCC by reducing PTSD and overall morbidity resulting from inadequate management of acute pain.


| Tags : douleur, morphine


Douleur: Pendant l'évacuation, Kétamine = Morphine ?

Prehospital Pain Medication Use by U.S. Forces in Afghanistan

Shackelford SA et Al. Mil Med. 2015 Mar;180(3):304-9


We report the results of a process improvement initiative to examine the current use and safety of prehospital pain medications by U.S. Forces in Afghanistan. Prehospital pain medication data were prospectively collected on 309 casualties evacuated from point of injury (POI) to surgical hospitals from October 2012 to March 2013. Vital signs obtained from POI and flight medics and on arrival to surgical hospitals were compared using one-way analysis of variance test. 119 casualties (39%) received pain medication during POI care and 283 (92%) received pain medication during tactical evacuation (TACEVAC). Morphine and oral transmucosal fentanyl citrate were the most commonly used pain medications during POI care, whereas ketamine and fentanyl predominated during TACEVAC.


Ketamine was associated with increase in systolic blood pressure compared to morphine (+7 ± 17 versus −3 ± 14 mm Hg, p = 0.04). There was no difference in vital signs on arrival to the hospital between casualties who received no pain medication, morphine, fentanyl, or ketamine during TACEVAC. In this convenience sample, fentanyl and ketamine were as safe as morphine for prehospital use within the dose ranges administered. Future efforts to improve battlefield pain control should focus on improved delivery of pain control at POI and the role of combination therapies.

| Tags : kétamine

Douleur: Kétamine d'abord ?

Prehospital and En Route Analgesic Use in the Combat Setting: A Prospectively Designed, Multicenter, Observational Study

Lawrence N. Petz  LN et Al. , Mil Med. 2015 Mar;180(3 Suppl):14-8



Combat injuries result in acute, severe pain. Early use of analgesia after injury is known to be beneficial. Studies on prehospital analgesia in combat are limited and no prospectively designed study has reported the use of analgesics in the prehospital and en route care setting. Our objective was to describe the current use of prehospital analgesia in the combat setting.



This prospectively designed, multicenter, observational, prehospital combat study was undertaken at medical treatment facilities (MTF) in Afghanistan between October 2012 and September 2013. It formed part of a larger study aimed at describing the use of lifesaving interventions in combat. On arrival at the MTF, trained on-site investigators enrolled eligible patients and completed standardized data capture forms, which included the name, dose, and route of administration of all prehospital analgesics, and the type of provider who administered the drug. Physiological data were retrospectively ascribed as soon as practicable. The study was prospectively approved by the Brooke Army Medical Center institutional review board.


Data were collected on 228 patients, with 305 analgesia administrations recorded. The predominant mechanism of injury was blast (50%), followed by penetrating (41%), and blunt (9%). The most common analgesic used was ketamine, followed by morphine.


A combination of analgesics was given to 29% of patients; the most common combination was ketamine and morphine. Intravenous delivery was the most commonly used route (55%). Patients transported by the UK Medical Emergency Response Team (MERT) or U.S. Air Medical Evacuation (Dust-off) team were more likely to receive ketamine than those evacuated by U.S. Pararescue Jumpers (Pedro). Patients transported by Medical Emergency Response Team or Pedro were more likely to receive more than 1 drug. Patients who received only ketamine had a higher pulse rate ( p < 0.005) and lower systolic blood pressure ( p = 0.01) than other groups, and patients that received hydromorphone had a lower respiratory rate ( p = 0.04).

Conclusions: In our prospectively designed, multicenter, observational, prehospital combat study, ketamine was the most commonly used analgesic drug. The most frequently observed combination of drugs was ketamine and morphine. The intravenous route was used for 55% of drug administrations.


| Tags : kétamine


Kétamine: Oui, à la bonne dose

Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial.

Beaudoin FL et Al. Acad Emerg Med. 2014 Nov;21(11):1193-202


Low-dose ketamine has been used perioperatively for pain control and may be a useful adjunct to intravenous (IV) opioids in the control of acute pain in the emergency department (ED). The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients.


A double-blind, randomized, placebo-controlled trial with three study groups was conducted at a large, urban academic ED over a 10-month period. Eligible patients were 18 to 65 years old with acute moderate to severe pain (score of at least 5 out of 10 on the numerical pain rating scale [NRS] and pain duration < 7 days) who were deemed by their treating physician to require IV opioids. The three study groups were: 1) morphine and normal saline placebo (standard care group), 2) morphine and 0.15 mg/kg ketamine (group 1), or 3) morphine and 0.3 mg/kg ketamine (group 2). Participants were assessed at 30, 60, and 120 minutes after study medication administration and received rescue analgesia as needed to target a 50% reduction in pain. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the NRS and calculated as the summed pain-intensity (SPID) difference over 2 hours. The amount and timing of rescue opioid analgesia was evaluated as a secondary outcome. The occurrence of adverse events was also measured.


Sixty patients were enrolled (n = 20 in each group). There were no differences between study groups with respect to age, sex, race/ethnicity, preenrollment analgesia, or baseline NRS. Over the 2-hour poststudy medication administration period, the SPIDs were higher (greater pain relief) for the ketamine study groups than the control group (standard care 4.0, interquartile range [IQR] = 1.8 to 6.5; group 1 7.0, IQR = 4.3 to 10.8; and group 2 7.8, IQR = 4.8 to 12.8; p < 0.02). The SPIDs for the ketamine groups were similar (p < 0.46). When compared to standard care, group 2 sustained the reduction in pain intensity up to 2 hours, whereas group 1 was similar to standard care by 2 hours. Similar numbers of patients received rescue analgesia: standard care group, seven of 20, 35%; group 1, four of 20, 20%; and group 2, four of 20, 20% (p = 0.48). Among those receiving rescue analgesia, those in the standard care group received analgesia sooner than either low-dose ketamine group, on average. More participants in the low-dose ketamine groups reported dysphoria and dizziness.


Low-dose ketamine is a viable analgesic adjunct to morphine for the treatment of moderate to severe acute pain. Dosing of 0.3 mg/kg is possibly more effective than 0.15 mg/kg, but may be associated with minor adverse events. Future studies should evaluate additional outcomes, optimum dosing, and use in specific populations.


| Tags : analgésie


Morphine mieux que kétamine ?

Comparison of the effects of ketamine and morphine on performance of representative military tasks.

Gaydos SJ et Al. J Emerg Med. 2015 Mar;48(3):313-24


Même un militaire blessé peut avoir à recourir à son arme. L'administration d'antalgiques peut interférer avec son niveau de vigilance. La kétamine semble être sur ce point moins maniable que la morphine du moins dans ce travail américain qui fait appel à l'administration intramusculaire, voie qui n'est pas usuelle dans notre pratique.



When providing care under combat or hostile conditions, it may be necessary for a casualty to remain engaged in military tasks after being wounded. Prehospital care under other remote, austere conditions may be similar, whereby an individual may be forced to continue purposeful actions despite traumatic injury. Given the adverse side-effect profile of intramuscular (i.m.) morphine, alternative analgesics and routes of administration are of interest. Ketamine may be of value in this capacity.


To delineate performance decrements in basic soldier tasks comparing the effects of the standard battlefield analgesic (10 mg i.m. morphine) with 25 mg i.m. ketamine.


Representative military skills and risk propensity were tested in 48 healthy volunteers without pain stimuli in a double-blind, placebo-controlled, crossover design.


Overall, participants reported more symptoms associated with ketamine vs. morphine and placebo, chiefly dizziness, poor concentration, and feelings of happiness. Performance decrements on ketamine, when present, manifested as slower performance times rather than procedural errors.



Participants were more symptomatic with ketamine, yet the soldier skills were largely resistant to performance decrements, suggesting that a trained task skill (autonomous phase) remains somewhat resilient to the drugged state at this dosage. The performance decrements with ketamine may represent the subjects' adoption of a cautious posture, as suggested by risk propensity testing whereby the subject is aware of impairment, trading speed for preservation of task accuracy. These results will help to inform the casualty care community regarding appropriate use of ketamine as an alternative or opioid-sparing battlefield analgesic.


| Tags : analgésie


Tramadol: Utilisation raisonnée et sereine

Tramadol use and the risk of hospitalization for hypoglycemia in patients with noncancer pain (1).  Jean-Pascal Fournier, Laurent Azoulay, Hui Yin, Jean-Louis Montastruc, Samy Suissa
Commentaires d’Hélène Beloeil, pour le conseil scientifique de la société française d’Anesthésie et de Réanimation.
Après le retrait du dextropropoxyphène en 2011, les restrictions à la prescription de codéine (2) suite à une publication (3) en 2013, le tramadol, seul médicament antalgique de palier 2 encore disponible fait aussi l’objet de surveillance et d’alertes. Suite au retrait du dextropropoxyphène, les ventes de tramadol ont progressé de 30 % dans l’année qui a suivi. Cette augmentation de consommation s’est accompagnée d’une recrudescence des déclarations d’évènements indésirables (+15%) sur la même période. Ces évènements étaient principalement psychiatriques (16%), vertiges, somnolence, syncope, convulsions (15%), nausées et vomissements (12%) et enfin des hyponatrémies et hypoglycémies (4). Parallèlement, des cas de  dépendance et un syndrome de sevrage suite à un usage abusif ont été décrits. L’ANSM a ainsi renforcé la surveillance de l’usage du tramadol en mettant en place un comité de pharmacovigilance et d’addictovigilance en 2012. Malgré un avis favorable au maintien du tramadol de la commission de transparence de la HAS en mars 2014, les alertes ont été reprises par les médias nationaux en septembre 2014. Dans ce contexte de restrictions à la prescription des médicaments antalgiques de palier 2 et 1 (restrictions à l’utilisation du diclofenac par l’european medicines agency en juin 2013, notamment), la données scientifiques et les recommandations des sociétés savantes vont toutes dans le sens d’un bénéfice à la réduction des consommations de morphine et donc à l’utilisation d’une analgésie multimodale. Il y a là une impasse…
L’article commenté ici, publié dans le JAMA à la fin de l’année 2014, s’est intéressé au risque d’hypoglycémie associé à la prise de tramadol en comparaison avec la codéine. Ce risque avait déjà été décrit dans ces cas cliniques. Les auteurs ont réalisé une étude cas-témoin rétrospective sur une cohorte de plus de 330 000 patients. Les auteurs ont réalisé 3 analyses successives: 1) étude cas (tramadol) - témoins (codéine), 2) une analyse de cohorte avec calcul de score de propension et 3) une analyse de cas en « crossover » dans laquelle chaque cas est son propre contrôle. Pour chaque patient il y a une période pendant laquelle le patient est un cas (prise de tramadol) et une période pendant laquelle le patient n’est pas un cas (avant ou après la prise de tramadol). L’exposition au risque d’hypoglycémie pendant ces deux périodes a été comparée.
Les résultats de leur analyse montrent que le risque d’hospitalisation pour hypoglycémie est deux fois plus important lors de la prise de tramadol que de codéine. Ce risque est particulièrement élevé dans les 30 premiers jours de traitement. Il est identique chez les patients traités par antidiabétiques laissant supposer que le diabète n’est pas un facteur de risque surajouté. L’incidence de l’hypoglycémie secondaire à la prise de tramadol est de 7 pour 10 000 ce qui en fait un effet secondaire rare et donc non rapporté dans les études randomisées.
Les propriétés analgésiques du tramadol passent par 2 mécanismes d’action : agoniste faible pour les récepteurs aux opiacés et inhibition de la recapture de la sérotonine et de la noradrénaline. Les voies sérotoninergiques ont des effets sur la régulation du glucose. La sérotonine peut induire des hypoglycémies chez des animaux diabétiques. Ceci reste à confirmer mais pourrait expliquer les hypoglycémies secondaires à la prise de tramadol.
A partir de la même cohorte de patients et en appliquant une méthodologie identique, les auteurs ont également retrouvé un risque augmenté d’hyponatrémie lors de la prise de tramadol comparé à la codéine (5). Là encore,  les auteurs précisent que le mécanisme d’action du tramadol peut expliquer cet effet secondaire. Les autres médicaments inhibiteurs de la recapture de la sérotonine (type anti-dépresseurs) sont, par ailleurs, connus pour entraîner des hyponatrémies et hypoglycémies.
Au final, cet article confirme l’existence d’effets secondaires rares mais potentiellement graves associés à la prescription de tramadol. Ceux ci doivent être connus des prescripteurs et intégrés dans les informations aux patients. Cet article ne doit pas, cependant entraîner une nouvelle restriction à l’utilisation des antalgiques. Il faut insister sur le bénéfice à l’utilisation des associations d’antalgiques qui permettent d’assurer une analgésie de qualité tout en diminuant les posologies de chacun des médicaments et donc, souvent, également les effets secondaires associés.
1.         Fournier JP, Azoulay L, Yin H, Montastruc JL, Suissa S. Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients With Noncancer Pain. JAMA internal medicine 2014.
2.         Médicaments contenant du diclofénac, de l'hydroxyéthylamidon, de la codéine (pour l'enfant) et solutions pour nutrition parentérale pour prématurés: avis et recommandations du PRAC. wwwansmfr 2013.
3.         Racoosin JA, Roberson DW, Pacanowski MA, Nielsen DR. New evidence about an old drug--risk with codeine after adenotonsillectomy. N Engl J Med 2013;368:2155-7.
4.         pharmacovigilance Cnd.  2012.
5.         Fournier JP, Yin H, Nessim SJ, Montastruc JL, Azoulay L. Tramadol for non-cancer pain and the risk of hyponatremia. The American journal of medicine 2014.

| Tags : douleur


Lidocaïne intraarticulaire: A ne pas oublier

Intra-articular lidocaine versus intravenous analgesia and sedation for manual closed reduction of acute anterior shoulder dislocation: an updated meta-analysis

Jiang N et Al.  J Clin Anesth. 2014 Aug;26(5):350-9


Une révision de la revue cochrane de  2011. La lidocaïne intraveineuse est efficace plus rapidement (attendre 5 minutes avant réduction) mais a pour inconvénient d'avoir plus de complications que lors d'une injection intraarticulaire (attendre au moins 15 minutes avant réduction)



To compare intra-articular lidocaine (IAL) with intravenous analgesia and sedation (IVAS) for manual closed reduction of acute anterior shoulder dislocation.




Metropolitan medical university.


A literature search was conducted of PubMed, Ovid and Cochrane Library, to identify randomized controlled trials (RCTs) published from January 1, 1990 to September 1, 2012, that compared IAL with IVAS for manual closed reduction of acute anterior shoulder dislocation. Effective data were pooled using fixed-effects or random-effects models with mean differences (MDs) and risk ratios (RRs) for continuous and dichotomous variables, respectively.


Nine RCTs comprising 438 patients were analyzed. Statistical analyses showed that IAL was superior to IVAS with respect to lower complication risk (P < 0.00001) and shorter mean hospital length of stay (P = 0.03). No significant differences were noted in success of joint reduction (P = 0.16), patient satisfaction (P = 0.12), or postreduction pain relief (P = 0.76). However, IAL required more time than IVAS from injection to reduction (P < 0.00001). Subgroup analyses showed that IVAS was associated with higher risks of respiratory depression (P < 0.0001), vomiting (P = 0.04), and thrombophlebitis (P = 0.008), but no statistical differences were identified in nausea (P = 0.06), hypotension (P = 0.10), drowsiness (P = 0.45), or headache (P = 0.29).


Intra-articular lidocaine injection may be safer than IVAS because there are fewer risks of postoperative complications with IAL. Both techniques are similarly effective for manual closed reduction of acute anterior shoulder dislocation.



Douleur du combattant blessé

La prise en charge de la douleur à l'avant fait appel à l'association de mesures passant par les immobilisations, le recours à la morphine sous cutanée, le paracétamol et dès que possible certaines techniques d' ALR. Les US viennent de proposer l'évolution de leur vision des choses.


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| Tags : douleur, analgésie


Douleur et dossiers UPSA


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| Tags : douleur douleur


La douleur: S'en occuper ACTIVEMENT

Pain Following Battlefield Injury and Evacuation: A Survey of 110 Casualties from the Wars in Iraq and Afghanistan

Buckenmaier III CC et All. Pain Med. 2009 Nov;10(8):1487-96.

Objective. Advances in regional anesthesia, specifically continuous peripheral nerve blocks (CPNBs), have greatly improved pain outcomes for wounded soldiers in Iraq and Afghanistan. Painmanagement practice variations, however, do exist, depending on the availability of pain-trained military professionals deployed to combat support hospitals. An exploratory study was undertaken to examine pain and other outcomes during evacuation and at Landstuhl Regional Medical Center (LRMC), Germany. 

Design. A mixed-methods, semistructured interview survey design was conducted on a convenience sample of wounded U.S. soldiers evacuated from Iraq and Afghanistan to LRMC. Setting and Patients. A total of 110 wounded soldiers evacuated from Iraq and Afghanistan from July 2007 to February 2008 completed a pain survey at LRMC. Data were collected on demographics, injury mechanism, last 24-hour average, least, and worst, and pain now by using a 0–10 scale, and percent pain relief (from 0% [No relief] to 100% [Complete relief]). Similar items and measures of anxiety, distress, and worry during flight transport were measured (from 0 [None] to 10 [Extreme]). Responses were analyzed by using descriptive and correlational statistics, multiple linear regression, Mann–Whitney U-tests, and t-tests. The Walter Reed Army Medical Center, Human Use Committee approved this investigation.

Results. Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = -0.58 and r = -0.46, respectively; P < 0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P < 0.05).


Average percent pain relief achieved was 45.2%  26.6% during transport and 64.5%  23.5% while at LRMC (P < 0.001).


Participants with CPNB catheters placed at LRMC reported significantlyy less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs


Conclusions. Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes