Prehospital and emergency department analgesia for air-transported patients with fractures

OBJECTIVE: To evaluate prehospital and receiving emergency department (ED) analgesia administration in air-transported patients with isolated fractures. METHODS: The study was a retrospective descriptive analysis of flight and hospital records. Study patients were consecutive adults (not pharmacologically paralyzed) with fractures undergoing scene or interfacility helicopter transport during 1994-1996. The study aeromedical program uses two helicopters staffed by a nurse/paramedic flight crew providing protocol-guided care. The receiving ED was in an urban academic Level I trauma center (annual census 65,000). Primary data collected were timing and amount of prehospital and ED analgesia. Analysis was mainly descriptive, with chi-square and nonparametric methods used to compare patients who did and did not receive intratransport fentanyl. RESULTS: 130 patients with isolated fractures underwent air transport during the study period 1994-1996. Of these, 98 (75.4%) received intratransport fentanyl; 20 of 98 (20.4%) received no analgesia in the receiving ED. Patients who did receive repeat analgesia in the receiving ED (n = 78, 79.6% of those receiving prehospital fentanyl) had a median interval of 42.5 minutes (interquartile range 25-100) between ED arrival and analgesia administration; only 62.8% of these patients received their ED analgesia within 60 minutes of arrival. CONCLUSIONS: Some patients receiving intratransport fentanyl received no ED analgesia, and those who did receive ED analgesia often had administration delays surpassing the clinical half-life of intratransport-administered fentanyl. Further study should investigate whether setting-specific analgesia practice differences reflect true differences in analgesia needs, overmedication by prehospital providers, or undermedication by ED staff.