An Evidence-based Guideline for Prehospital Analgesia in Trauma

<b>Background.</b> The management of acute traumatic pain is a crucial component of prehospital care and yet the assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based regional protocols. <b>Objective.</b> To develop an evidence-based guideline (EBG) for the clinical management of acute traumatic pain in adults and children by advanced life support (ALS) providers in the prehospital setting. <b>Methods.</b> We recruited a multi-stakeholder panel with expertise in acute pain management, guideline development, health informatics, and emergency medical services (EMS) outcomes research. Representatives of the National Highway Traffic Safety Administration (sponsoring agency) and a major children's research center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide the process of question formulation, evidence retrieval, appraisal/synthesis, and formulation of recommendations. The process also adhered to the National Prehospital Evidence-Based Guideline (EBG) model process approved by the Federal Interagency Council for EMS and the National EMS Advisory Council. <b>Results.</b> Four strong and three weak recommendations emerged from the process; two of the strong recommendations were linked to high- and moderate-quality evidence, respectively. The panel recommended that all patients be considered candidates for analgesia, regardless of transport interval, and that opioid medications should be considered for patients in moderate to severe pain. The panel also recommended that all patients should be reassessed at frequent intervals using a standardized pain scale and that patients should be re-dosed if pain persists. The panel suggested the use of specific age-appropriate pain scales. <b>Conclusion.</b> GRADE methodology was used to develop an evidence-based guideline for prehospital analgesia in trauma. The panel issued four strong recommendations regarding patient assessment and narcotic medication dosing. Future research should define optimal approaches for implementation of the guideline as well as the impact of the protocol on safety and effectiveness metrics.**背景**：急性创伤疼痛管理是院前急救的核心组成部分，但镇痛措施的评估与给药方案差异显著，往往未达最优标准，且通常由基于共识的区域诊疗方案所决定。 **目的**：旨在为院前环境下高级生命支持（Advanced Life Support, ALS）从业者对成人与儿童急性创伤疼痛的临床管理制定循证指南（Evidence-Based Guideline, EBG）。 **方法**：本研究组建了多利益相关方专家小组，成员涵盖急性疼痛管理、指南制定、健康信息学及急诊医疗服务（Emergency Medical Services, EMS）结局研究领域的专家。美国国家公路交通安全管理局（项目资助方）及一家大型儿童研究中心（研究团队）的代表也参与了本次指南制定流程。专家小组采用推荐分级、评估、制定与评价（Grading of Recommendations Assessment, Development and Evaluation, GRADE）方法，指导问题构建、证据检索、评价与整合以及推荐意见的形成。本流程同时遵循由联邦跨部门EMS委员会与国家EMS咨询委员会批准的《国家院前循证指南（EBG）》标准流程。 **结果**：本次流程共形成4项强推荐意见与3项弱推荐意见，其中2项强推荐意见分别基于高质量与中等质量证据。专家小组建议：所有患者无论转运时长如何，均应考虑给予镇痛治疗；对于中至重度疼痛患者，应考虑使用阿片类药物。同时建议所有患者需采用标准化疼痛量表进行频繁的疼痛评估复查，若疼痛持续则应追加给药剂量。此外，专家小组建议选用适配特定年龄层的疼痛评估量表。 **结论**：本研究采用GRADE方法制定了创伤患者院前镇痛的循证指南。专家小组就患者评估与阿片类药物给药方案提出了4项强推荐意见。未来研究应明确该指南的最佳实施路径，以及该方案对安全性与有效性指标的影响。