Evidence-Based Guidelines for Prehospital Pain Management: Recommendations

Figures & data

Table 1. Members of the technical expert panel.

Name	Primary Affiliation	Expertise
George Lindbeck Principal Investigator National Association of State EMS Officials	University of Virginia School of Medicine, Virginia State EMS & Trauma Systems Medical Director	Emergency Medicine, EMS Medical Direction
Sabina Braithwaite Co – PI American College of Emergency Physicians	Washington University School of Medicine, State of Missouri EMS Medical Director	Emergency Medicine, EMS Medical Direction
Manish I. Shah Co- PI National Association of EMS Physicians	Baylor College of Medicine	Pediatric Emergency Medicine, EMS Research
Lorin Browne	Medical College of Wisconsin, Milwaukee County EMS	Pediatric Emergency Medicine, EMS Medical Direction
Brooke Burton	Falck Ambulance Northern California	EMS Performance Improvement and System/Data Interoperability
Jeffrey Coughenour	University of Missouri Healthcare, Frank Mitchell, Jr, MD, Trauma Center	Trauma/Acute Care Surgeon
Remle Crowe	ESO	EMS Research
James J. Gasper	California Department of Health Care Services	Substance Use Disorder Pharmacology
Eddy S. Lang	Cumming School of Medicine - University of Calgary and Alberta Health Services	Evidence-Based Medicine (GRADE Methodology), Emergency Medicine
Connie J. Mattera	Northwest Community Hospital and EMS System	EMS/Trauma Education
Sandra Nasca	EMS for Children Family Advocacy Network	Patient Advocate, Clinical Forensics, Emergency Medicine
Ashish R Panchal	National Registry of EMTs, The Ohio State University Wexner Medical Center	EMS Research, Emergency Medicine, EMS Medical Direction
Peter Taillac	State of Utah EMS Medical Director University of Utah School of Medicine	Emergency Medicine, EMS Medical Direction
Mark Warth	Colorado Springs Fire Department	EMS Education and Quality Assurance
Jonathan Powell	National Registry of EMTs	EMS Research Fellow
Kyle D. Guild	Cumming School of Medicine - University of Calgary	Medical Student
Mary Hedges	National Association of State EMS Officials	Project Manager
Hannah Degn	National Association of State EMS Officials	Project Coordinator
Dia Gainor	National Association of State EMS Officials	Executive Director

Table 2. PICO questions for the EBG for prehospital pain management.

1.  Should intranasal fentanyl vs. IV opioids be used for acute onset of moderate to severe pain in children in the prehospital setting?

2.  Should IV acetaminophen (APAP) vs. IV opioids be used for treatment of moderate to severe pain in the prehospital setting?

3.  Should IV non-steroidal anti-inflammatory drugs (NSAIDs) vs. IV opioids be used for treatment of moderate to severe pain in the prehospital setting?

4.  Should IV APAP vs. IV NSAIDs be used for treatment of moderate to severe pain in the prehospital setting?

5.  Should IV ketamine vs. IV NSAIDs be used for treatment of moderate to severe pain in the prehospital setting?

6.  Should IV ketamine vs. IV opioids be used for treatment of moderate to severe pain in the prehospital setting?

7.  Should IV morphine vs. IV fentanyl be used for treatment of moderate to severe pain in the prehospital setting?

8.  Should a combination of weight based IV opioid plus IV ketamine vs. weight based IV opioid alone be used for treatment of moderate to severe pain in the prehospital setting?

9.  Should a combination of IV opioid plus IV ketamine vs. IV ketamine alone be used for treatment of moderate to severe pain in the prehospital setting?

10. Should nitrous oxide vs. IV opioids be used for treatment of moderate to severe pain in the prehospital setting?

Table 3. Summary of judgements and recommendations for each PICO question identified by the TEP.

	Intranasal fentanyl vs IV opioids in children	IV APAP vs IV opioids	IV NSAIDs vs IV opioids	APAP vs NSAIDs	IV ketamine vs IV NSAID
Problem	Yes	Yes	Yes	Yes	Yes
Desirable effects	Trivial	Trivial	Don’t know	Trivial	Trivial
Undesirable effects	Trivial	Moderate	Trivial	Trivial	Moderate
Certainty of evidence	Very low	Low	Moderate	Very low	Moderate
Values	Possibly important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	Probably no important uncertainty or variability	Probably no important uncertainty or variability
Balance of effects	Probably favors the intervention	Probably favors the intervention	Does not favor either the intervention or the comparison	Does not favor either the intervention or the comparison	Don’t know
Resources required	Negligible costs and savings	Don’t know	Negligible costs and savings	Moderate costs	Negligible costs and savings
Certainty of evidence of required resources	No included studies	No included studies	No included studies	No included studies	No included studies
Cost effectiveness	No included Studies	No included studies	Does not favor either the intervention or the comparison	No included studies	No included studies
Equity	Probably increased	Don’t know	Don’t know	Don’t know	Don’t know
Acceptability	Yes	Probably yes	Yes	Probably yes	Probably yes
Feasibility	Probably yes	Probably yes	Yes	Varies	Probably yes
Type of recommendation	Strong recommendation for the intervention (fentanyl prior to or without IV access)	Conditional recommendation for the intervention (APAP) if acceptable cost and ease of administration	Conditional recommendation for either the intervention or the comparison	Conditional recommendation for the comparator (NSAID) when IV, either when PO.	Conditional recommendation for either the intervention or the comparison
	IV ketamine vs IV opioids	IV morphine vs IV fentanyl	Combination weight based IV opioid plus IV ketamine vs weight based IV opioid	IV opioid plus iv ketamine vs iv ketamine	Inhaled nitrous oxide inhaled vs IV opioid
Problem	Yes	Yes	Yes	Yes	Yes
Desirable effects	Trivial	Trivial	Trivial	Don’t know	Don’t know
Undesirable effects	Small	Small	Small	Don’t know	Don’t know
Certainty of evidence	Very low	Low	Very low	Very low	Very low
Values	Probably no important uncertainty or variability	Probably no important uncertainty or variability	Possibly important uncertainty or variability	No important uncertainty or variability	Possibly important uncertainty or variability
Balance of effects	Does not favor either the intervention or the comparison	Does not favor either the intervention or the comparison	Does not favor either the intervention or the comparison	Don’t know	Don’t know
Resources required	Negligible costs and savings	Negligible costs and savings	Negligible costs and savings	Don’t know	Don’t know
Certainty of evidence of required resources	No included studies	No included studies	No included studies	No included studies	No included studies
Cost effectiveness	No included studies	No included studies	No included studies	No included studies	No included studies
Equity	Don’t know	Don’t know	Don’t know	Don’t know	Don’t know
Acceptability	Probably yes	Probably yes	Probably no	Probably yes	Yes
Feasibility	Probably yes	Yes	Probably yes	Probably yes	Yes
Type of recommendation	Conditional recommendation for either the intervention or the comparison	N/A, two recommendations listed	Conditional recommendation against the intervention (combination)	No recommendation due to significant uncertainty	No recommendation