Nasal nalbuphine analgesia in prehospital trauma managed by first-responder personnel on ski slopes in Switzerland: an observational cohort study

Abstract

Background: Pain is one of the major symptoms complained about by patients in the prehospital setting, especially in the case of trauma. When there is mountainous topography, as in Switzerland, there may be a time delay between injury and arrival of professional rescuers, in particular on ski slopes. Administration of a safe opioid by first responders may improve overall treatment. We therefore assessed administration of nasal nalbuphine as an analgesic treatment for trauma patients in Switzerland.

Methods: This observational cohort study examined 267 patients who were treated with nasal nalbuphine by first responders in six ski resorts in Switzerland. All first responders were instructed to begin treatment by assessing the feasibility of using nalbuphine to treat pain in the patient. A treatment algorithm was developed and distributed to assure that nalbuphine was only administered following a strict protocol. Data regarding pain scores and pain reduction after administration of nalbuphine were collected on-site. Refills were handed out to the first responders with the return of each completed questionnaire.

Results: Nalbuphine provided effective pain relief, with the median level of pain on the numeric rating scale for pain reduced by 3 units on average, from 8 points (p < 0.001). The multivariate regression model showed that pain reduction was more pronounced in patients with higher initial pain levels. Nalbuphine was more effective in adolsecents than in patients aged 20 to 60 years (p = 0.006). No major side effects were observed.

Conclusion: Nasal administration of nalbuphine by first responders is a presumably safe and effective noninvasive pain management strategy for acutely injured patients in the prehospital setting. This may be an alternative, especially in the case of severe pain and prolonged time between arrival of the first responders and arrival of EMS/HEMS personnel on scene.

Keywords: Emergency medicine; Nalbuphine; Pain; Prehospital analgesia; Trauma; Wilderness medicine.

Fig. 1

Treatment algorithm that had to be followed by the lay rescuers to assure the drug was administered only if indicated. NRS = numeric rating scale. GCS = Glasgow coma scale. Noticeable altered vital signs = Airway – threatened, respiratory rate > 36 or < 8 or SpO₂ < 90%, Circulation - pulse > 140 or < 40, systolic Bloodpressure < 90 or > 180

Fig. 2

Distribution of pain reduction depending on initial pain level and dose applied. Footnote: To increase readability of the plot, the points were jittered around the true value. One hundred forty five patients had pain reduction of at least 3 units on the numeric rating scale. Absolute pain reduction in NRS points as reported by the trauma victims (left panel). The dotted line indicates the median pain reduction of 3 NRS units. Due to heteroscedasticity in pain reduction depending on the initial pain level, relative pain reduction was calculated and is presented as a percentage scale (right panel)

Fig. 3

Initial pain level (NRS) versus pain level after administration of nalbuphine. Footnote: The initial pain level was reported in all patients. Information on pain level after administration of nalbuphine was missing in 19 of 267 patients. The difference in pain level was significant, p < 0.001 (Wilcoxon signed-rank test)