Intranasal sufentanil given in the emergency department triage zone for severe acute traumatic pain—a randomized double-blind controlled trail: comment

Abstract

We read with great interest the article by Lemoel et al. [1] previously published online in Internal and Emergency Medicine. This paper evaluated whether a single dose of intranasal (IN) sufentanil delivered in the triage zone of an emergency department would improve the management of severely painful adult patients with a limb injury (LI), receiving an intravenous (IV) multimodal analgesia (including opioids if needed). The authors considered IN analgesia in case of delayed care in an overcrowded emergency department. As military physicians, we would like to share our experience of IN analgesia in another context: i.e. tactical medicine. The first special medical unit (French 1st AMS) provides tactical emergency medical support during Gendarmerie Nationale Intervention Group’s (GIGN) operations. GIGN is a French counter-terrorism unit specializing in neutralizing terrorists on the national territory. A tactical medical team composed of a physician-nurse pair joins every counterterrorism troop. They both belong to the French Military Medical Service (FMMS) and have significant experience in war injuries management [2]. The 1st AMS is engaged on the police operations restricted area. In connection with civilian emergency services [3], it represents the first level of care, with restricted capacities as each medical operator carries limited portable medical equipment. In an unsafe, austere or remote environment, close to the terrorist threat, IN analgesia as proposed by Lemoel et al. is an “efficient, safe and non-invasive alternatives to IV analgesia” [1]. Indeed, IN analgesia can be delivered faster than IV analgesia. It can be performed in a few minutes, even during tactical phases. It is also an efficient way to gain time in order to ensure both patient’s and medical team’s safety. The 1st AMS has developed its own IN analgesia protocol‚ with a dose of 0.6 mg/ kg of sufentanil. It is implemented in the case of an isolated LI, either operator or hostage, while the police action is still taking place. During this initial management, performing IN analgesia allows the physician to follow the end of the action with the remaining troop, while the nurse cares for the patient. Our experience revealed the absence of serious adverse events associated with IN sufentanil analgesia. More interestingly, Lemoel’s contribution could help us to extend our IN analgesia protocol. In case of mass civilian shootings, patients with chest or abdominal injuries‚ or uncontrolled bleeding LI are treated in priority, whereas the population studied by Lemoel, i.e. isolated LI, will be exposed to delayed evacuations and care. IN analgesia would be delivered after an initial tactical triage while waiting for evacuations. A second step, utilizing IV opioids, will be performed by civilian prehospital emergency services at a casualty collection point located in the safety zone [3]. IN analgesia offers thereby a first management to LI, making the stretcher phase less painful, improving their well-being and decreasing potential agitation. At the dose of 0.4 mg/kg, within the framework of a strict survey protocol, Lemoel did not report any serious adverse events such as somnolence, emesis or respiratory depression. Moreover, side-effects were assessed after opioid IV injection. We can estimate that a single sufentanil IN use will decrease their risk of * Simon-Pierre Corcostegui [email protected]