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)

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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).

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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. 

 

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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.

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INTRODUCTION:

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.

METHODS:

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.

RESULTS:

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.

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.

CONCLUSION:

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.

 

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.

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

 

 Background:

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.

 

Methods:

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.

Results:

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.

 

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

OBJECTIVES:

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.

METHODS:

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.

RESULTS:

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.

CONCLUSIONS:

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.

 

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

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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.

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BACKGROUND:

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.

OBJECTIVES:

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.

METHODS:

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

RESULTS:

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.

CONCLUSIONS:

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.

 

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.
 
Références
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. http://www.ansm.fr.  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.

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

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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)

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STUDY OBJECTIVE:

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

DESIGN:

Meta-analysis.

SETTING:

Metropolitan medical university.

MEASUREMENTS:

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.

MAIN RESULTS:

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).

CONCLUSIONS:

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.

Clic sur l'image pour accéder au document

 

Douleur et dossiers UPSA

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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

Analgésie du combattant:Le point US

Pain Management Task Force - Final Report - May 2010

Providing a Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and their Families

http://www.amedd.army.mil/reports/Pain_Management_Task_Fo...

Analgésie du combattant: Une vision anglaise

End-to-end military pain management

Hocking G et all. J R Army Med Corps 1999; 145: 116-118

 

La prise en charge de la douleur du combattant. Les propositions ne sont pas récentes

Morphine: Mieux avec UN PEU de kétamine

Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial

Jennings et all. Ann Emerg Med. 2012;59:497-503.

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.

 

 Pour l'analgésie, La kétamine s'emploi à PETITES DOSES car c'est un coantalgique

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Recours à la morphine et PTSD

 Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder.

Holbrook TL et all. N Engl J Med 2010;362:110-7.

 

Background

Post-traumatic stress disorder (PTSD) is a common adverse mental health outcome among seriously injured civilians and military personnel who are survivors of trauma. Pharmacotherapy in the aftermath of serious physical injury or exposure to traumatic events may be effective for the secondary prevention of PTSD.

Methods

We identified 696 injured U.S. military personnel without serious traumatic brain injury from the Navy–Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database. Complete data on medications administered were available for all personnel selected. The diagnosis of PTSD was obtained from the Career History Archival Medical and Personnel System and verified in a review of medical records.

 

 

Results

Among the 696 patients studied, 243 received a diagnosis of PTSD and 453 did not. The use of morphine during early resuscitation and trauma care was significantly associated with a lower risk of PTSD after injury. Among the patients in whom PTSD developed, 61% received morphine; among those in whom PTSD did not develop, 76% received morphine (odds ratio, 0.47; P<0.001). This association remained significant after adjustment for injury severity, age, mechanism of injury, status with respect to amputation, and selected injury-related clinical factors.

Conclusions

Our findings suggest that the use of morphine during trauma care may reduce the risk of subsequent development of PTSD after serious injury.

 

 

La douleur du blessé de guerre: La vision UK

http://rstb.royalsocietypublishing.org/content/366/1562/2...

Lidocaïne intraarticulaire et réduction de luxation d'épaule

 Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature

Viktor K et all. Can J Rural Med 2009; 14 (4)

Introduction :

Parmi les blessures affectant des articulations majeures, ce sont celles de l’épaule qui amènent le plus de patients à se présenter à l’urgence d’un hôpital de nos jours. Dans la communauté, l’incidence des blessures à l’épaule est de 11,2 cas  par 100000années-personne. On a généralement recours à la sédation-analgésie perthérapeutique pour faciliter la réduction des luxations antérieures de l’épaule. On
note toutefois certains risques de complications, comme la dépression respiratoire, particulièrement dans certaines populations, d’où la suggestion d’utiliser de la lidocaïne intra-articulaire comme méthode analgésique de rechange.

Méthodes :

Nous avons interrogé les bases de données EMBASE (Ovid) et MEDLINE (PubMed) à partir des mots clés «shoulder, dislocation et/ou reduction» (épaule, luxation et/ou réduction) pour la période allant de la date respective de mise en service des deux bases de données jusqu’à octobre 2008.

Résultats :

Selon la littérature actuelle, il semble que la lidocaïne intra-articulaire  procure au moins le même degré de contrôle et de soulagement de la douleur que la  sédation-analgésie perthérapeutique, tout en réduisant nettement la durée des séjours à l’urgence et le coût du traitement. Il y a lieu de croire que la probabilité de complications serait moindre avec la lidocaïne intra-articulaire.

Conclusion :

 Il faudra approfondir la recherche dans ce domaine, mais les médecins peuvent d’ores et déjà envisager la lidocaïne intra-articulaire comme solution de rechange à la sédation-analgésie perthérapeutique pour la réduction des luxations antérieures de l’épaule.

 Autres références: 1  2  3  4  5  

 

Lidocaïne intra-articulaire pour luxation d'épaule

Intra-articular lidocaine for the reduction of posterior shoulder dislocation

Socransky SJ et all. CJEM 2005;7(6):423-426 

 

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La luxation antérieure de l’épaule est le type de luxation le plus souvent rencontré au département d'urgence. La lidocaïne intra-articulaire est une méthode analgésique efficace pour faciliter la réduction de cette luxation. La luxation postérieure représente un faible pourcentage des luxations de l'épaule. Nous présentons un cas de luxation postérieure de l'épaule chez une patiente âgée; la réduction fut effectuée à la suite d'une injection intra-articulaire de lidocaïne, une solution de rechange utile pour faciliter la réduction des luxations de l'épaule, en particulier chez les patients à risque plus élevé de complications liées à la sédation.

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Analgésie Sédation préhospitalière

http://www.sfmu.org/documents/consensus/rfe_sedation_anal...

Bloc abdominal

http://www.anesthesia-analgesia.org/cgi/reprint/104/1/193...