Prehosp Emerg Care. 2020 Mar-Apr;24(2):163-174. doi: 10.1080/10903127.2019.1657213. Epub 2019 Sep 23.
: The objectives of this study were to assess comparative effectiveness and harms of opioid and nonopioid analgesics for the treatment of moderate to severe acute pain in the prehospital setting. : We searched MEDLINE, Embase, and Cochrane Central from the earliest date through May 9, 2019. Two investigators screened abstracts, reviewed full-text files, abstracted data, and assessed study level risk of bias. We performed meta-analyses when appropriate. Conclusions were made with consideration of established clinically important differences and we graded each conclusion's strength of evidence (SOE). : We included 52 randomized controlled trials and 13 observational studies. Due to the absence or insufficiency of prehospital evidence we based conclusions for initial analgesia on indirect evidence from the emergency department setting. As initial analgesics, there is no evidence of a clinically important difference in the change of pain scores with opioids vs. ketamine administered primarily intravenously (IV) (low SOE), IV acetaminophen (APAP) (low SOE), or nonsteroidal anti-inflammatory drugs (NSAIDs) administered primarily IV (moderate SOE). The combined use of an opioid and ketamine, administered primarily IV, may reduce pain more than an opioid alone at 15 and 30 minutes (low SOE). Opioids may cause fewer adverse events than ketamine (low SOE) when primarily administered intranasally. Opioids cause less dizziness than ketamine (low SOE) but may increase the risk of respiratory depression compared with ketamine (low SOE), primarily administered IV. Opioids cause more dizziness (moderate SOE) and may cause more adverse events than APAP (low SOE), both administered IV, but there is no evidence of a clinically important difference in hypotension (low SOE). Opioids may cause more adverse events and more drowsiness than NSAIDs (low SOE), both administered primarily IV. : As initial analgesia, opioids are no different than ketamine, APAP, and NSAIDs in reducing acute pain in the prehospital setting. Opioids may cause fewer total side effects than ketamine, but more than APAP or NSAIDs. Combining an opioid and ketamine may reduce acute pain more than an opioid alone but comparative harms are uncertain. When initial morphine is inadequate, giving ketamine may provide greater and quicker acute pain relief than giving additional morphine, although comparative harms are uncertain. Due to indirectness, strength of evidence is generally low, and future research in the prehospital setting is needed.
本研究旨在评估阿片类药物和非阿片类药物在院前环境中治疗中重度急性疼痛的疗效和安全性。
我们检索了 MEDLINE、Embase 和 Cochrane Central 从最早日期到 2019 年 5 月 9 日的文献。两名调查员筛选摘要、审查全文文件、提取数据并评估研究水平的偏倚风险。我们在适当的时候进行了荟萃分析。结论考虑了既定的临床重要差异，并对每个结论的证据强度（SOE）进行了分级。
我们纳入了 52 项随机对照试验和 13 项观察性研究。由于缺乏或不足的院前证据，我们基于急诊科环境中的间接证据来确定初始镇痛的结论。作为初始镇痛剂，与主要静脉内（IV）给予阿片类药物相比，静脉内给予酮胺（低 SOE）、IV 乙酰氨基酚（APAP）（低 SOE）或非甾体抗炎药（NSAIDs）（中等 SOE），在疼痛评分变化方面没有临床重要差异。主要静脉内给予阿片类药物和酮胺联合使用可能比单独使用阿片类药物在 15 分钟和 30 分钟时更能减轻疼痛（低 SOE）。与主要鼻内给予相比，阿片类药物引起的不良反应少于酮胺（低 SOE）。与主要静脉内给予相比，阿片类药物引起的头晕少于酮胺（低 SOE），但可能增加呼吸抑制的风险（低 SOE）。与 IV 给予的 APAP（低 SOE）相比，阿片类药物引起的头晕（中等 SOE）和不良反应更多，但低血压（低 SOE）方面无临床重要差异。与主要静脉内给予的 NSAIDs（低 SOE）相比，阿片类药物引起的不良反应和嗜睡更多。
作为初始镇痛剂，阿片类药物与酮胺、APAP 和 NSAIDs 一样，在院前环境中减轻急性疼痛方面没有差异。阿片类药物引起的总副作用可能少于酮胺，但多于 APAP 或 NSAIDs。联合使用阿片类药物和酮胺可能比单独使用阿片类药物更能减轻急性疼痛，但比较危害尚不确定。如果初始吗啡不足，给予酮胺可能比给予额外吗啡更快地缓解急性疼痛，但比较危害尚不确定。由于间接性，证据强度普遍较低，需要在院前环境中进行进一步的研究。
