giving Narcotics like candy

[Dustdevil]

If you act in the best interest in your patients and stand behind that...you will never go wrong.

Spoken like a man who has never been fired for acting in his patient's best interest.

Trust me, you can definitely "go wrong" acting in your patient's best interest. But yeah, it's still the right thing to do.

[Ace844]

Another study which is no surprise...~!!!

(Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences @ part of the Taylor & Francis Group

Issue: Volume 10, Number 1 / January-March 2006

Pages: 1 - 7

URL: Linking Options

DOI: 10.1080/10903120500373264

Safety and Effectiveness of Fentanyl Administration for Prehospital Pain Management

Arthur Kanowitz A1, Thomas M. Dunn A2, A3, Elyse M. Kanowitz A4, William W. Dunn A1, A5, Kayleen VanBuskirk A4

A1 Pridemark Paramedic Services, Arvada, Colorado

A2 University of Northern Colorado, Department of Psychology, Greeley, Colorado

A3 Pridemark Paramedic Services, Boulder, Colorado

A4 Department of Biology, Colorado Springs, Colorado

A5 Paramedic Division, Denver Health Medical Center, Denver, Colorado)

Abstract:

Objective. To determine the safety and effectiveness of fentanyl administration for prehospital pain management. Methods. This was a retrospective chart review of patients transported by ambulance during 2002–2003 who were administered fentanyl citrate in an out-of-hospital setting. Pre- and post-pain-management data were abstracted, including vital signs, verbal numeric pain scale scores, medications administered, and recovery interventions. In addition, the emergency department (ED) charts of a subgroup of these patients were reviewed for similar data elements. Results. Of 2,129 patients who received fentanyl for prehospital analgesia, only 12 (0.6%) had a vital sign abnormality that could have been caused by the administration of fentanyl. Only one (0.2%) of the 611 patients who had both field and ED charts reviewed had a vital sign abnormality that necessitated a recovery intervention. There were no admissions to the hospital, nor patient deaths, attributed to fentanyl use. There was a statistically significant improvement in subjective pain scale scores (8.4 to 3.7). Clinically, this correlates with improvement from severe to mild pain. Conclusion. This study showed that fentanyl was effective in decreasing pain scores without causing significant hypotension, respiratory depression, hypoxemia, or sedation. Thus, fentanyl citrate can be used safely and effectively for pain management in the out-of-hospital arena.

(Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences @ part of the Taylor & Francis Group

Issue: Volume 10, Number 1 / January-March 2006

Pages: 71 - 76

URL: Linking Options

DOI: 10.1080/10903120500366086

Effects of an Educational Intervention on Prehospital Pain Management

Scott C. French A1, A2, Nabil P. Salama A1, Serena Baqai A1, Sonja Raslavicus A1, Jill Ramaker A3, Shu B. Chan A1

A1 Resurrection Emergency medicine Residency program, Resurrection medical Center, Chicago, Illinois

A2 St. Francis Hospital, Resurrection Hospital, Evanston, Illinois

A3 Evanston Hospital, Evanston Northwestern Healthcare, Evanston, Illinois)

Abstract:

Introduction. Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting. Objectives. To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers. Methods. All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests. Results. The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%–20.2%; p < 0.001). Paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%–39.2%; p < 0.001), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%–57.9%; p < 0.001) improvement in documentation of pain severity, 24% (95% CI: 21.2%–26.8%; p < 0.001) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%–18.7%; p < 0.001) improvement in pain reassessment following intervention. Conclusion. As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.

[Ace844]

(Acad Emerg Med Volume 13 @ Number 5 493-499,

published online before print March 28, 2006, doi: 10.1197/j.aem.2005.12.013

© 2006 Society for Academic Emergency Medicine CLINICAL INVESTIGATION

Age Effect on Efficacy and Side Effects of Two Sedation and Analgesia Protocols on Patients Going through Cardioversion: A Randomized Clinical Trial

Mine Parlak, MD, Ismet Parlak, MD, Bulent Erdur, MD, Ahmet Ergin, MD, PhD, MPH and Emel Sagiroglu, MD

From the Departments of Anesthesiology (MP, ES) and Emergency Medicine (IP), Dokuz Eylul University, Izmir; and the Departments of Emergency Medicine (BE) and Public Health (AE), Pamukkale University, Denizli, Turkey.

Address for correspondence and reprints: Bulent Erdur, MD, Pamukkale Universitesi Tip Fakultesi Hastanesi Acil Tip AD, Kinikli-Denizli, Turkey. Fax: 90 258 213 49 22; e-mail: bulenterdur@hotmail.com.)

Background: Cardioversion (CV), a painful procedure, requires sedation and analgesia. Although several sedation agents currently are in use for CV, data on age-specific efficacy and side effects of midazolam and propofol have been limited.

Objectives: To compare the efficacy and side effects of midazolam and propofol in patients of two different age groups, younger than 65 years and 65 years and over, who were going through CV.

Methods: Seventy consented patients with CV indications caused by atrial fibrillation were included in this clinical trial. The participants were placed into four groups by using a stratified randomization method: patients aged younger than 65 years who were receiving midazolam (n = 12) or propofol (n = 11) and patients 65 years and over who were receiving midazolam (n = 25) or propofol (n = 22). Medications were administered by slow intermittent bolus injections. During CV, time to reach Ramsay Sedation Scale level 5 (RSS-5; induction time); time to reach RSS-2 (recovery time); and side effects including desaturation, apnea, and changes in hemodynamic parameters were recorded by a person blinded to the patient treatment allocation.

Results: Mean induction time was similar in all four groups. Mean recovery time (min ± SD) was shorter in both propofol groups when compared with both midazolam groups: 18.8 (± 4.06) and 40.33 (± 20.8) in the group younger than 65 years and 18.2 (± 5.12) and 54.2 (± 20.85) in the group 65 years or older, respectively (p < 0.001). Older participants in each medication group needed less medication than younger patients. There were no hemodynamic differences between the groups. Desaturation was higher in both midazolam groups as compared with individuals in the age-matched propofol groups (both p < 0.05). Patient reactions were less in propofol groups with similar joules during CV procedures than were those in the midazolam groups.

Conclusions: Propofol appears to be a better choice for CV sedation in elders because of its short recovery time, fewer side effects, and its more comfortable sedative effect.

[Ace844]

Here's a study on subject from a local Flt service and which another member {not sure 100%} may have been involved with...

HTH,

ACE844

(The American Journal of Emergency Medicine

Volume 24 @ Issue 3 , May 2006, Pages 286-289

doi:10.1016/j.ajem.2005.11.021

Copyright © 2006 Elsevier Inc. All rights reserved.

Original Contribution

Efficacy of fentanyl analgesia for trauma in critical care transport

Michael A. Frakes APRN, CCNS, CFRN, CCRN, EMTPa, b, , , Wendy R. Lord BSN, CCRN, EMTPa, Christine Kociszewski MPH, EMTPb and Suzanne K. Wedel MDb

aLIFE STAR/Hartford Hospital, Hartford, CT 06102-5037, USA

bBoston MedFlight, Boston, MA 01730, USA

Received 20 October 2005; revised 27 November 2005; accepted 28 November 2005. Available online 25 April 2006.)

Abstract

Introduction

Pain relief is one of the most important interventions for out-of-hospital patient care providers. This paper documents the need for and benefits from the administration of fentanyl to trauma patients during critical care transport.

Methods

We underwent a retrospective review of the transport charts of 100 trauma patients who received fentanyl analgesia during transport and who were able to use a numeric response scale to rate their pain from 0 to 10.

Results

Mean initial pain report was 7.6 ± 2.2 units, relieved to 3.7 ± 2.8 units by a mean total fentanyl dose of 1.6 ± 0.8 μg/kg (P < .001). Neither initial pain level nor pain relief differed between male and female patients, but did differ between patients originating at the site of injury and those transferred between hospitals. Fentanyl dose correlated poorly with the magnitude of pain relief (r = 0.22), but a dose greater than 2 μg/kg provided more relief than lower doses (5.1 ± 2.1 vs 3.6 ± 2.4, P < .02).

Conclusion

Fentanyl analgesia from these critical care transport teams provided significant pain relief to trauma patients. Pain reduction was greater for patients who received more than 2.0 μg/kg of fentanyl.

Article Outline

1. Introduction

2. Methods

3. Results

4. Discussion

5. Conclusion

References

1. Introduction

Pain relief is an important practice focus for healthcare systems [1], [2] and [3]. The Emergency Medical Services Outcomes Project, a 5-year National Highway Traffic Safety Administration project designed to develop a foundation and framework for out-of-hospital research, identified discomfort relief as one of the most relevant outcome parameters for out-of-hospital patient care. In fact, those authors suggested that analgesia might be the out-of-hospital intervention with the greatest patient effect [4]. The National Association of EMS Physicians has similarly articulated a position that pain relief must be a priority for every emergency medical services (EMS) system [5]. Nevertheless, trauma patients receive analgesia from out-of-hospital providers at rates between 1.8% and 84.1% [6], [7], [8], [9], [10], [11], [12] and [13]. Administration rates seem to be higher for patients transported by dedicated critical care transport teams than for those transported by ground EMS [11], [12] and [13].

A number of factors suggest that fentanyl may be the preferred agent for out-of-hospital analgesia administration. It reaches peak effect rapidly, probably allowing safer titration and decreasing the potential for oversedation. In addition, the absence of a histamine release after administration reduces the risks for hypotension and nausea [14]. Finally, fentanyl has a short effective period, reducing the possibility of masking changes in mental status or physical examination by the receiving hospital [14], [15], [16] and [17]. In addition to these clinical advantages, the literature indicates that fentanyl is clearly safe when used for in-transport analgesia by critical care providers. Several reports from such teams have demonstrated the absence of significant changes or complications in systolic blood pressure, oxygen saturation, Glasgow Coma Scale, and end-tidal carbon dioxide after single and multiple doses of fentanyl analgesia for trauma [11], [12], [13], [18], [19] and [20].

In this body of literature, there are little reported objective data on the benefit or effectiveness of fentanyl analgesia in an out-of-hospital transport setting. This paper analyzes patient self-reports of pain to evaluate the need for and outcomes from fentanyl administration by dedicated critical care transport teams during critical care transport.

2. Methods

We undertook a retrospective review of consecutive transport charts from trauma patients who received fentanyl analgesia during transport by a specialty critical care transport team and who were able to use a Numeric Response Scale (NRS) to rate their pain. The literature on pain assessment tools describes patient self-report as the most reliable indicator of pain existence and intensity. One-dimensional pain scales such as the NRS or Adjective Rating Scale are recommended for emergency and out-of-hospital settings, and the NRS appears to be the tool most readily completed by diverse populations [21], [22] and [23]. The Emergency Medical Services Outcomes Project recommends the NRS for out-of-hospital pain outcomes research [4]. The minimum change required for clinical significance on an 11-point NRS anchored with 0 as pain-free and 10 as maximal pain is 1.3 units [24].

Data are reported from 100 patients, with 50 from each of 2 critical care transport programs operating in overlapping service areas in New England. Records were from consecutive transports in third quarter of 2004, with the omission of records that did not have both initial and final NRS pain documentation. A total of 132 consecutive records were reviewed to gather the 100 that had complete documentation.

The programs have generally similar operational profiles and medical practice standards, and both are members of the North East Air Alliance, a confederation of critical care transport programs with a history of collaborative operations. One program is a multimodal transport entity with fixed-wing, rotor-wing, and ground assets. The practice standards and transport team members are the same for all transport modes. The second program provides strictly rotor wing transport. Each uses a critical care transport nurse partnered in one case with a paramedic and, in the other, with a respiratory therapist. Both programs administer fentanyl for analgesia to trauma patients under protocols that do not require on-line medical direction, and patient care at each program is subject to intensive retrospective quality improvement processes. The maximum protocol doses of fentanyl at the 2 programs are 5 and 2 μg/kg, with individual doses and administration frequencies at the discretion of the clinicians. Each program also carries morphine, but the practice standards clearly identify fentanyl as the preferred analgesic for trauma patients. Institutional review boards at each organization approved the project.

Each chart was abstracted by one of the authors, all of whom have at least 5 years of specialty experience in the field. The data for initial pain report, final pain report, site of origin (scene vs hospital), patient sex, and fentanyl dose are all specifically recorded in the transport charts and that information was transferred without interpretation into the research database. Pain reports were patient self-reports obtained by the transport team at the beginning and end of their encounter with the patient.

Descriptive statistics and frequencies are reported. Comparisons of means were performed with paired-sample and independent-sample t tests, as appropriate. When those means involved groups with statistically significantly different starting points, a 1-way analysis of variance was used to control for that covariation. The strength of the linear relationship between dose and response was evaluated with the Pearson correlation. The sample size provided 80% power to detect a difference of 1.3 units to a 2-sided .05 significance level [25].

3. Results

Pain documentation included an NRS report for initial and postintervention pain in 75.6% of patients. Accordingly, 132 records were reviewed to obtain the 100 needed for data analysis.

There were 61 male and 39 female patients retrieved evenly from scene (50%) and hospital (50%) locations. The mean patient age was 36.92 ± 17.9 years (range, 6-82 years). Overall, the mean initial pain report was 7.6 ± 2.2 units on a 0- to 10-unit NRS. After a mean fentanyl dose of 1.6 ± 0.8 μg/kg, patients reported a mean pain of 3.7 ± 2.8 units on arrival at the receiving hospital. The pain change in transport was significant (P < .001). There was no difference in initial pain level or in pain relief between male and female patients.

Initial pain level was higher for patients originating at scenes than for those originating at hospitals (8.1 ± 1.9 vs 7.0 ± 2.4, P < .02). However, the magnitude of pain relief was greater for interhospital patients than for scene patients, with a change of 4.5 ± 2.5 units for patients being transported between hospitals and 3.2 ± 2.1 for those transported from the site of injury (P < .01).

The amount of fentanyl used for analgesia correlated poorly with the magnitude of pain relief (r = 0.22). Pain reduction was significantly greater for patients receiving a total fentanyl dose of more than 2 μg/kg than for those receiving less than that amount (5.1 ± 2.1 vs 3.6 ± 2.4 units, P < .02). That difference was not appreciated when patients were grouped by doses of 1.0 or 1.5 μg/kg.

There were practice and outcome differences between the 2 programs. The mean initial pain report was higher at one program than at the other (7.8 ± 1.9 vs 7.4 ± 2.5 units, P < .02). However, the mean fentanyl dose was higher at the second program (1.9 ± 0.9 vs 1.2 ± 0.6 μg/kg, P < .01). Similarly, the covariate-controlled mean pain reduction was higher at the program administering a higher mean fentanyl dose: 4.6 ± 2.4 vs 3.2 ± 2.2 units (P < .01). The program with higher mean medication doses and pain reduction was the program whose protocols allow administration of a higher maximum fentanyl dose.

4. Discussion

Pain reduction is a priority outcome for out-of-hospital providers. This project augments the existing literature about the safety of fentanyl analgesia during transport of trauma patients by demonstrating a clear need for and benefit from that analgesia in critical care transport from both scene and hospital sites. The reported pain reduction is statistically significant and is well above the described threshold for clinical significance. In addition, when common correlations between the Adjective Rating Scale and NRS are used, the reported pain decreased from “very severe” to “moderate” [3].

It is interesting that there is poor correlation between analgesic dose and analgesic effectiveness. Two possible explanations for this poor relationship include the individualized nature of pain and analgesia experiences and the relatively low dose of fentanyl provided. Drug response often follows an S-shaped curve [24]. The recommended initial analgesic doses for fentanyl are between 1.0 and 3.0 μg/kg, with much higher doses in some circumstances, so it may be that the 1.6 μg/kg mean dose provided to these patients is on the left tail of the “S,” below a dose where the correlation would be stronger [11] and [23]. That conjecture is supported by the greater pain reduction effect, seen by patients receiving doses greater than 2.0 μg/kg than by those receiving less than that amount, and by the increased overall analgesic effect that is demonstrated by the transport team providing a higher mean fentanyl dose. Although the analgesia dose should always be individualized and titrated to patient response, identification of a safe dose range that best precludes oligoanalgesia seems an important area for continued research.

The high initial pain reports in patients being transported from hospitals were unexpected. With the known low rates of out-of-hospital analgesia administration, the high initial pain reports of scene patients are not unexpected. However, there have been comprehensive pain management guidelines and recommendations for hospitals since the early 1990s [2]. This series included 50 patients who had contact with a hospital emergency center, yet presented for transport with a mean pain of 7 on a 0 to 10 scale. This “very severe” pain confirms the conclusions of other papers indicating that pain management is still not optimized in hospital settings. Admittedly, patients requiring subsequent critical care transport from the sending hospital likely represent a higher acuity subgroup of patients seen by the referring emergency departments, but the current results are still consistent with previous reports of emergency department oligoanalgesia and delays to analgesia of up to 113 minutes [7], [13] and [26]. The reasons for this are unclear and would also be a useful area for ongoing investigation.

Pain decrease was greater for patients transported from hospitals than for those transported from the site of injury. A likely explanation for this is that patients on interhospital transports are more likely to have vascular access, some measure of exposure and evaluation, and splints and dressings in place before the arrival of the transport team. Conceivably, this would allow the team a greater time for attention to other interventions. This is strictly conjecture, and there may be other factors. This represents yet another opportunity for additional investigation.

The frequency of pain documentation by the critical care transport team identifies an important point. Documentation deficiencies are one of the factors cited as contributing to ineffective pain management [3]. Patient satisfaction and pain management outcomes are improved when there is reliable documentation of initial and subsequent pain assessments [27], [28], [29] and [30]. Although there was objective pain scale documentation for about 75% of the patients in this report, the omission of that data for nearly one quarter may represent a population at risk for oligoanalgesia.

5. Conclusion

The studied dedicated critical care transport teams provided significant pain relief from fentanyl administration during the transport of trauma patients from both scene and hospital locations. There was a poor correlation between analgesic dose and analgesic effect, but there was a significantly greater amount of pain reduction for patients who received more than 2.0 μg/kg of fentanyl.

There are numerous additional opportunities for research in this area, particularly in establishing the reasons for oligoanalgesia in trauma patients and in identifying optimal medication doses.

References

[1] Joint Commission on Accreditation of Healthcare Organizations, Current understanding of assessment, management, and treatments Retrieved March 1, 2004 fromhttp://www.jcaho.org/news+room/health+care+issues/pain_mono_npc.pdf..

[2] U.S. Department of Health and Human Services, Acute pain management: operative or medical procedures and trauma, US Public Health Service, Rockville (Md) (1992).

[3] National Pharmaceutical Council, Inc, Improving the quality of pain management through measurement and action Retrieved March 1, 2004 fromhttp://www.jcaho.org/news+room/health+care+issues/pain_mono_jc.pdf..

[4] R.F. Maio, H.G. Garrison, D.W. Spaite, J.S. Desmond, M.A. Gregor and C.G. Cayten et al., Emergency Medical Services Outcomes Project I (EMSOP I): prioritizing conditions for outcomes research, Ann Emerg Med 33 (1999) (4), pp. 423–432. SummaryPlus | Full Text + Links | PDF (84 K)

[5] H.M. Alonso-Serra and K. Wesley, Prehospital pain management, Prehosp Emerg Care 7 (2003), pp. 482–488. Abstract-MEDLINE

[6] C.C. McEachin, J.T. McDermott and R. Swor, Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia, Prehosp Emerg Care 6 (2002) (4), pp. 406–410. Abstract

[7] F.B. Abbuhl and D.B. Reed, Time to analgesia for patients with painful extremity injuries transported to the Emergency Department by ambulance, Prehosp Emerg Care 7 (2003), pp. 445–447. Abstract-MEDLINE

[8] L. Fullerton-Gleason, C. Crandall and D.P. Sklar, Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication, Prehosp Emerg Care 6 (2002) (4), pp. 411–416. Abstract

[9] L.J. White, J.D. Cooper, R.M. Chambers and R.E. Gradisek, Prehospital use of analgesia for suspected extremity fractures, Prehosp Emerg Care 4 (2000) (3), pp. 205–208. Abstract

[10] E.T. Dickinson, F.W. Wurster, C.C. Mechem and I.M. Reyes, Prehospital utilization and effectiveness of morphine (abstract), Prehosp Emerg Care 8 (2004), p. 103.

[11] S.H. Thomas, O. Rago, T. Harrison, P.D. Biddinger and S.K. Wedel, Fentanyl trauma analgesia use in air medical scene transports, J Emerg Med 29 (2005) (2), pp. 179–187. SummaryPlus | Full Text + Links | PDF (129 K)

[12] P. DeVellis, S.H. Thomas, R.J. Vinci and S.K. Wedel, Prehospital fentanyl analgesia in air-transported pediatric trauma patients, Pediatr Emerg Care 14 (1998), pp. 321–323. Abstract-EMBASE | Abstract-MEDLINE

[13] P. DeVellis, S.H. Thomas and S.K. Wedel, Prehospital and emergency department analgesia for air-transported patients with fractures, Prehosp Emerg Care 2 (1998), pp. 293–296. Abstract-MEDLINE

[14] D. Braude and M. Richards, Appeal for fentanyl prehospital use, Prehosp Emerg Care 8 (2004) (4), pp. 441–442. Abstract

[15] S.H. Thomas, W. Silen, F. Cheema, A. Reisner, S. Aman and G.N. Goldstein et al., Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: a prospective, randomized trial, J Am Coll Surg 196 (2003), pp. 18–31. SummaryPlus | Full Text + Links | PDF (218 K)

[16] S.H. Thomas and W. Silen, Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain, Br J Surg 90 (2003) (1), pp. 5–9. Abstract-MEDLINE | Abstract-EMBASE | Abstract-Elsevier BIOBASE | Full Text via CrossRef

[17] M.S. Kim, R.T. Strait, T.T. Saio and H.M. Hennes, A randomized clinical trial of analgesia in children with acute abdominal pain, Acad Emerg Med 9 (2002) (4), pp. 281–287. Abstract-MEDLINE | Abstract-EMBASE | Full Text via CrossRef

[18] S.H. Thomas, W. Benevelli, D.F.M. Brown and S.K. Wedel, Safety of fentanyl for analgesia in adults undergoing air medical transport from trauma scenes, Air Med J 15 (1996) (2), pp. 57–59.

[19] T.H. Harrison, W. Ahmed, S.H. Thomas and S.K. Wedel, Effect of fentanyl on end-tidal carbon dioxide in air-transported patients (abstract), Ann Emerg Med 36 (2000), p. 4.

[20] A.A. Aronson, S.H. Thomas, T. Harrison, M. Saia and H. Bach, Use of end-tidal carbon dioxide monitoring to detect occult hypoventilation in patients receiving opioids in the pre-hospital and emergency department settings (abstract), Chest 126 (2004) (4), p. 907S.

[21] B. Blettery, L. Ebrahim and D. Honnart, Pain scale in an emergency care unit, Reanim Urgences 5 (1996), pp. 691–697. Abstract

[22] D.E. Fosnocht, C.R. Chapman, E.R. Swanson and G.W. Donaldson, Correlation of change in the visual analog scale with pain relief in the ED, Am J Emerg Med 23 (2005) (1), pp. 55–58.

[23] A. Ricard-Hibon, C. Chollet and S. Saada, A quality control program for acute pain management in out-of-hospital critical care medicine, Ann Emerg Med 34 (1999), pp. 738–744. SummaryPlus | Full Text + Links | PDF (43 K)

[24] K.H. Todd and J.P. Funk, The minimum clinically important difference in physician-assigned visual analog pain scores, Acad Emerg Med 3 (1996), pp. 142–146. Abstract-MEDLINE | Abstract-EMBASE

[25] R.G. O'Brien and K.E. Muller, Applied analysis of variance in behavioral science, Dekker, New York (1993).

[26] B.G. Katzung, Basic and clinical pharmacology, McGraw-Hill, New York (2001).

[27] D.E. Fosnocht, E.R. Swanson and P. Bossart, Patient expectations for delivery of pain medication, Am J Emerg Med 19 (2001) (5), pp. 399–402. Abstract | PDF (33 K)

[28] S.C. Eder, E.P. Sloan and K. Todd, Documentation of ED patient pain by nurses and physicians, Am J Emerg Med 21 (2003) (4), pp. 253–257. SummaryPlus | Full Text + Links | PDF (70 K)

[29] S.H. Thomas and L.M. Andruszkiewicz, Ongoing visual analog score display improves emergency department pain care, J Emerg Med 26 (2004) (4), pp. 389–394. SummaryPlus | Full Text + Links | PDF (86 K)

[30] I.E. Scott, Effectiveness of documented assessment of post-operative pain, Br J Nurs 3 (1994), pp. 494–501. Abstract-MEDLINE