Hudson Ian L, Staudt Amanda M, Burgess Matthew, Hinojosa-Laborde Carmen, Schauer Steven G, Newberry Ryan K, Ryan Kathy L, VanFosson Christopher A
Brooke Army Medical Center, San Antonio, TX 78234, USA.
US Army Institute of Surgical Research, San Antonio, TX 78234, USA.
Mil Med. 2023 Jan 4;188(1-2):108-116. doi: 10.1093/milmed/usac211.
Battlefield pain management changed markedly during the first 20 years of the Global War on Terror. Morphine, long the mainstay of combat analgesia, diminished in favor of fentanyl and ketamine for military pain control, but the options are not hemodynamically or psychologically equivalent. Understanding patterns of prehospital analgesia may reveal further opportunities for combat casualty care improvement.
Using Department of Defense Trauma Registry data for the Afghanistan conflict from 2005 to 2018, we examined 2,402 records of prehospital analgesia administration to assess temporal trends in medication choice and proportions receiving analgesia, including subanalysis of a cohort screened for an indication with minimal contraindication for analgesia. We further employed frequency matching to explore the presence of disparities in analgesia by casualty affiliation.
Proportions of documented analgesia increased throughout the study period, from 0% in 2005 to 70.6% in 2018. Afghan casualties had the highest proportion of documented analgesia (53.0%), versus U.S. military (31.9%), civilian/other (23.3%), and non-U.S. military (19.3%). Fentanyl surpassed morphine in the frequency of administration in 2012. The median age of those receiving ketamine was higher (30 years) than those receiving fentanyl (26 years) or nonsteroidal anti-inflammatory drugs (23 years). Among the frequency-matched subanalysis, the odds ratio for ketamine administration with Afghan casualties was 1.84 (95% CI, 1.30-2.61).
We observed heterogeneity of prehospital patient care across patient affiliation groups, suggesting possible opportunities for improvement toward an overall best practice system. General increase in documented prehospital pain management likely reflects efforts toward complete documentation, as well as improved options for analgesia. Current combat casualty care documentation does not include any standardized pain scale.
在全球反恐战争的头20年里，战场疼痛管理发生了显著变化。长期以来作为战斗镇痛主要药物的吗啡，在军事疼痛控制方面逐渐被芬太尼和氯胺酮所取代，但这些选择在血流动力学或心理方面并不等同。了解院前镇痛模式可能会为改善战斗伤员护理带来更多机会。
利用2005年至2018年阿富汗冲突期间国防部创伤登记数据，我们检查了2402份院前镇痛给药记录，以评估药物选择的时间趋势和接受镇痛的比例，包括对一组筛选出具有最小镇痛禁忌证的队列进行亚分析。我们还采用频率匹配来探讨不同伤亡归属群体在镇痛方面是否存在差异。
在整个研究期间，有记录的镇痛比例有所增加，从2005年的0%增至2018年的70.6%。阿富汗伤员有记录的镇痛比例最高（53.0%），而美军为（31.9%），平民/其他为（23.3%），非美军为（19.3%）。2012年，芬太尼的给药频率超过了吗啡。接受氯胺酮治疗的患者中位年龄（30岁）高于接受芬太尼治疗的患者（26岁）或非甾体抗炎药治疗的患者（23岁）。在频率匹配亚分析中，阿富汗伤员使用氯胺酮的优势比为1.84（95%CI，1.30 - 2.61）。
我们观察到不同患者归属群体的院前患者护理存在异质性，这表明朝着全面最佳实践系统改进可能存在机会。院前疼痛管理记录的普遍增加可能反映了完善记录的努力以及镇痛选择的改善。目前的战斗伤员护理记录不包括任何标准化疼痛量表。
