Administration of prehospital pain medication compared to eventual need among subjects of a randomized controlled trial [abstract]
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Background: Prehospital pain management continues to be a controversial factor in overall treatment of pain, especially in the pediatric population. The primary aim of this prospective, double-blinded, randomized control trial was to determine whether a single, subdissociative dose of ketamine would decrease the total narcotic requirements of pediatric emergency department (ED) patients compared to a group of patients who received morphine alone. Here, we present the frequency of prehospital opioid administration as compared to eventual need for treatment upon arrival at the ED. Methods: Patients aged 3–17 presenting to the ED with a condition requiring opioid pain management per standard of care were randomized to the study. After administration of either a single bolus of ketamine (0.3 mg/kg) or a single bolus of morphine (0.05 mg/kg), they were followed to determine if additional doses of morphine were needed. Retrospectively, we determined whether each subject was given prehospital pain medication by the emergency medical service (EMS). Results: Forty pediatric patients (mean age 13.0 ± 3.7, 35% female)were enrolled, all of whom were deemed to require opioid pain management per standard of care upon arrival at the ED. Twenty patients were randomized to each study arm and administered the assigned drug. EMS providers had previously administered an opioid (morphine, dilaudid, or fentanyl) to 23 (57.5%) of the study subjects. Seven of the ten subjects (70%) who went on to need additional doses of morphine in the first hour after study drug administration received prehospital pain medication. Twelve of the 19 subjects (63%) who received any post study drug morphine received prehospital treatment. Conclusions: Although all subjects in our study required intravenous pain management upon arrival at the ED, only 57.5% of the children received medication in the field. Medics may be apprehensive to administer narcotics to pediatric patients due to potential adverse event. Perhaps they would be willing to administer low-dose ketamine, an agent with intrinsic analgesic properties that has been shown to prevent opioid tolerance and opioid induced hyperalgesia. A larger trial is warranted that includes low dose ketamine as an option to prehospital providers.