Pre-hospital treatment of acute trauma pain: an observational study

Prospective cohort study conducted in the Immediate Life Support Ambulances in Portugal from March 1, 2019 to April 30, 2020. We have collected data on the kind of interventions implemented and the time elapsed during rescue procedures. To investigate the course of acute trauma pain, a 11-point Numeric Rating Scale was used. Changes in the level of pain registered throughout the three assessment moments were studied using linear mixed-effects models with random intercepts to account for the repeated measurements conducted on the same patient. These changes were assessed before and after the administration of the pain relief interventions.

Results

596 patients were included in this study. Most of them were male (65.9%) and had a mean age of 53.05±19.72 years. There was a reduction in the average pain intensity of 2.44 points (p<0.005), between the beginning and end of the assessment, and a reduction of 39.62% among the patients who were experiencing a level of pain equal to or greater than 7 (46.7% vs 7.08%, p<0.05). Measures involving the use of morphine, cryotherapy and relationship-based measures have proven to be effective. Comfort measures as a whole do not seem to have a significant impact on pain relief.

Conclusion

Pre-hospital pharmacological and non-pharmacological nurses’ interventions have proven to be effective in reducing pain. Comfort measures have not been proved to be effective, so their potential must be rethought and enhanced.

Pain management; Wounds and injuries; Pre-hospital care; Nursing care

Variables	Mean±SD	Median (IQR)
Age, years	53.05±19.72	54.0 (37.0-69.0)
Rescue time elapsed from the initial approach to presentation at the reference hospital, minutes	69.63±28.97	66.0 (48.0-85.0)

	n(%)

Gender, male	393(65.9)
Monotrauma/Politrauma	280/316(47.0%/53.0%)
Anatomical location of trauma,
Cranioencephalic trauma	261(43.8)
Neck trauma	97(16.3)
Thoracic trauma	204(34.2)
Abdominal trauma	101(16.9)
Pelvic trauma	85(14.3)
Upper limbs trauma	200(33.6)
Lower limbs trauma	232(38.9)
Vertebromedular trauma	131(22.0)
Type of trauma
Blunt	471(79.0)
Blunt and penetrating	30(5.0)
Penetrating	95(15.9)

Variable	n	Pain severity				Δ_PAIN^(d)		p-value
		Before the nurse’s intervention		After the nurse’s intervention		Δ_PAIN^(d)
		mean±SD	Md	mean±SD	Md	mean±SD	Md
Pain Severity		5.55±3.04	6	3.12±2.16	3	2.44±2.37	2	<0.005^(a)
NRS: 4-10		7.17±1.81	-	3.87±1.96	-	3.29±2.19	-	<0.005^(a)
NRS: 7-10		8.29±0.10	-	4.23±2.05	-	4.05±2.05	-	<0.005^(a)
NRS: 4-10, n(%)		404(71.50)		223(39.47)		-		<0.005^(b)
NRS: 7-10, n(%)		264(46.7)		40(7.08)		-		<0.005^(b)
Relationship-based measures
Yes	565	5.6±3.01	6	3.14±2.15	3	2.49±2.38	2	0.02^(c)*
No	31	4.21±3.35	3,5	2.68±2.29	2	1.54±1.95	1	0.02^(c)*
Pharmacological
Paracetamol
Yes	171	5.48±3.03	6	3.08±2.19	3	2.40±2.14	2	0.98^(c)
No	425	5.58±3.04	6	3.13±2.15	3	2.45±2.45	2	0.98^(c)
Tramadol
Yes	79	5.21±2.88	5	2.88±2.18	3	2.32±2.70	1	0.31^(c)
No	517	5.61±3.06	6	3.15±2.16	3	2.46±2.31	2	0.31^(c)
Morphine
Yes	252	5.89±2.89	7	3.26±2.21	3	2.63±2.31	3	0.11^(c)
No	344	5.30±3.12	5	3.01±2.12	3	2.29±2.40	2	0.11^(c)
Non-Pharmacological
Cryotherapy
Yes	107	5.88±2.87	7	2.94±1.97	3	2.94±2.50	3	0.05^(c)*
No	489	5.48±3.07	6	3.15±2.20	3	2.33±2.32	2	0.05^(c)*
Heat Application
Yes	15	6.00±2.63	8	2.67±1.72	3	3.33±2.31	3	0.17^(c)
No	581	5.54±3.05	6	3.12±2.17	3	2.42±2.37	2	0.17^(c)
Distraction
Yes	223	5.33±3.21	6	3.06±2.34	3	2.26±2.32	2	0.14^(c)
No	373	5.69±2.92	6	3.15±2.12	3	2.54±2.99	2	0.14^(c)
Immobilization
Yes	470	5.69±2.63	6	3.22±2.16	3	2.47±2.40	2	0.54^(c)
No	126	5.06±3.21	5	2.72±2.11	3	2.34±2.23	2	0.54^(c)
Extremity elevation
Yes	66	5.39±3.04	5	2.97±2.35	3	2.42±2.41	2	0.66^(c)
No	530	5.57±3.04	6	3.13±2.14	3	2.44±2.36	2	0.66^(c)
Presence of family and friends
Yes	144	5.30±3.02	5	3.07±2.12	3	2.23±2.31	2	0.30^(c)
No	452	5.63±3.04	6	3.13±2.18	3	2.5±2.40	2	0.30^(c)
Comfort measures
Yes	321	5.51±3.03	6	3.17±2.20	3	2.33±2.33	2	0.31^(c)
No	275	5.61±3.05	6	3.05±2.12	3	2.56±2.41	2	0.31^(c)

Variables	Unadjusted model		Adjusted model
Variables	Coefficient Estimate (SE)	p-value	Coefficient Estimate (SE)	p-value
Morphine – Morph
Morph (Yes)	0.52 (0.22)	0.02	0.39 (0.20)	0.06
T2	-1.37 (0.10)	<0.005	-1.37(0.10)	<0.005*
T3	-2.32 (0.11)	<0.005	-2.32 (0.11)	<0.005*
Morph*T2	-0.14 (0.16)	0.37	-0.15 (0.16)	0.36
Morph*T3	-0.33 (0.16)	0.04	-0.33 (0.16)	0.04*
Relationship-based Measures – Rel
Rel (Yes)	1.37 (0.48)	0.005	1.17 (0.46)	0.01*
T2	-0.93 (0.36)	0.009	-0.91 (0.36)	0.01*
T3	-1.51 (0.36)	<0.005	1.50 (0.36)	<0.005*
Rel*T2	-0.53 (0.3647)	0.15	-0.55 (0.36)	0.13
Rel*T3	-0.99 (0.37)	0.007	-1.00 (0.37)	0.006*
Non-pharmacological measures: Immobilization – Imob; Cryotherapy - Cryoth
Imob	0.60 (0.24)	0.01	0.43 (0.22)	0.05
Cryoth	0.36(0.28)	0.16	0.21 (0.27)	0.43
T2	-1.41 (0.09)	<0.005	-1.41 (0.09)	<0.005*
T3	-2.34 (0.09)	<0.005	-2.34 (0.09)	<0.005*
Cryoth*T2	-0.14 (0.21)	0.50	-0.14 (0.21)	0.50
Cryoth*T3	-0.62 (0.21)	0.003	-0.62 (0.21)	0.003*

Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
E-mail: actapaulista@unifesp.br

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[1] Corresponding author: Mauro Mota E-mail: maurolopesmota@gmail.com