Independent administration of the opioid analgesic piritramide by emergency paramedics: retrospective evaluation of electronic mission documentation

Background: Emergency medical services (EMS) frequently care for patients who require prehospital analgesia for severe pain. In the state of Bavaria in Germany, the medical directors of EMS have released uniform standing orders for the treatment of intolerable pain in patients with isolated limb injuries. These include the administration of the opioid analgesic piritramide in a dose of 7.5 mg by emergency paramedics without prior contact with a physician. We present a retrospective evaluation of effectiveness and safety of opioid analgesia administered independently by paramedics. Methods: Electronic patient records of all missions with treatment of severe pain according to the standing order for isolated limb injury in the Bavarian EMS were evaluated over a 2-year period. Analgesia was evaluated with respect to pain intensity on the numeric rating scale (NRS), the subjective presence of intolerable pain, vital function disturbances, and the need for further interventions. Results: The 7151 documented applications of the standing order "Isolated limb injury" resulted in 6097 piritramide infusions. The NRS level declined from a median of 7 (interquartile range [IQR] 2) to 3 (IQR 2, p < 0.001). After treatment, a tolerable pain level was achieved in 96.9% of cases. In 9.4%, a prehospital emergency physician was called to the scene, and 5.0% of patients received supplemental analgesia. One out of 10 patients was given oxygen. Airway interventions had to be performed in a few, isolated patients, whereas antagonization of the opioid was documented exclusively in cases with opioid doses exceeding those in the standing order. Discussion: The independent administration of opioid analgesia by paramedics following standard orders as issued by the EMS medical directors in Bavaria is safe and effective. Through this procedure, an estimated 2500 emergency physician dispatches could be avoided annually in Bavaria.