Analgesia in Patients with Trauma in Emergency Medicine

Abstract

Background: Suitable analgesic drugs and techniques are needed for the acute care of the approximately 18 200-18 400 seriously injured patients in Germany each year.

Methods: This systematic review and meta-analysis of analgesia in trauma patients was carried out on the basis of randomized, controlled trials and observational studies. A systematic search of the literature over the 10-year period ending in February 2016 was carried out in the PubMed, Google Scholar, and Springer Link Library databases. Some of the considered trials and studies were included in a meta-analysis. Mean differences (MD) of pain reduction or pain outcome as measured on the Numeric Rating Scale were taken as a summarizing measure of treatment efficacy.

Results: Out of 685 studies, 41 studies were considered and 10 studies were included in the meta-analysis. Among the drugs and drug combinations studied, none was clearly superior to another with respect to pain relief. Neither fentanyl versus morphine (MD -0.10 with a 95% confidence interval of [-0.58; 0.39], p = 0.70) nor ketamine versus morphine (MD -1.27 [-3.71; 1.16], p = 0.31), or the combination of ketamine and morphine versus morphine alone (MD -1.23 [-2.29; -0.18], p = 0.02) showed clear superiority regarding analgesia.

Conclusion: Ketamine, fentanyl, and morphine are suitable for analgesia in spontaneously breathing trauma patients. Fentanyl and ketamine have a rapid onset of action and a strong analgesic effect. Our quantitative meta-analysis revealed no evidence for the superiority of any of the three substances over the others. Suitable monitoring equipment, and expertise in emergency procedures are prerequisites for safe and effective analgesia by healthcare professionals..

Figure 1

PRISMA flow chart of literature survey and study selection

Figure 2

Post-therapeutic pain status according to Numeric Rating Scale (NRS) score after analgesia with fentanyl or morphine. The data showed no clear-cut advantage of fentanyl over morphine. IV, Inverse variance; Random, random effect; SD, standard deviation; 95% CI, 95% confidence interval

Figure 3

Post-therapeutic pain status after administration of ketamine or ketamine/morphine versus analgesia with morphine alone. Scores on the Numeric Rating Scale (NRS) show advantages for the ketamine combinations. IV, Inverse variance; Random, random effect; SD, standard deviation; 95% CI, 95% confidence interval

Figure 4

Pain reduction expressed as difference in scores on the Numeric Rating Scale (NRS) before and after analgesia with ketamine/morphine or ketamine alone and with morphine IV, Inverse variance; Random, random effect; SD, standard deviation; 95% CI, 95% confidence interval

eFigure

Risk of bias table according to the Cochrane Collaboration’s risk of bias tool. +, Low risk; ?, unclear risk; –, high risk.