Page 122 - JSOM Winter 2023

Drug-induced Asystole – Oral Transmucosal Fentanyl Citrate Analgesia
Damage Control in Penetrating Cardiac Injury in Prehospital Trauma Care: An Observational
Holger Rupprecht H, C. Neuner, Surgical Department of the Cohort Study
Clinic of Neumarkt, Academic Hospital of the University of Urs Pietsch 1,2,3 ; Henning Fischer ; Christoph Alexander Rüst ;
1
4
Erlangen-Nuremberg Björn Hossfeld ; Andreas Grünenfelder ; Volker Wenzel ;
7,8
5
6
enetrating cardiac injuries are usually already preclinically fa- Roland Albrecht 1,2,3
Ptal. Our two patients (aged 18 and 49 years) were admitted in 1. Department of Anesthesiology and Intensive Care Medicine,
stable condition as “thoracic trauma” after an accident at work Cantonal Hospital St. Gallen, St. Gallen, Switzerland. 2. Swiss
with a so-called pneumatic nailer and after a suicide attempt with Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne),
a letter opener, respectively. CT only revealed a perforation in the Zurich, Switzerland. 3. Department of Emergency Medicine,
myocardium, with a nail in the first case and a hemopericardium Inselspital, Bern UniversityHospital, University of Bern, Bern,
with an additional hemothorax in the second. Rapidly progressive Switzerland. 4. Department of Intensive Care Medicine, Cantonal
shock prevented transfer to a cardiac surgery center and required Hospital Frauenfeld, Frauenfeld, Switzerland. 5. Federal Armed
immediate sternotomy and pericardiotomy. After “explosive” Forces Hospital, Department of Anesthesiology, Intensive
evacuation of blood from the pericardium, both a barbed nail and Care Medicine, Emergency Medicine and Pain Therapy, and
a puncture in the left ventricle were found. For less hazardous HEMS, Christoph 22” Ulm, Ulm, Germany. 6. Department of
foreign body extraction or perforation suturing, 12mg of adenos- Anesthesiology, Klinik Gut, St. Moritz, Switzerland. 7. Department
ine was rapidly administered intravenously at a time to provoke of Anaesthesiology and Intensive Care Medicine, Friedrichshafen
short-term cardiac arrest. In both cases, a regular rhythm was Regional Hospital, Friedrichshafen, Germany. 8. Department of
spontaneously restored. In the case of the suicide attempt, addi- Anesthesiology, University of Florida, Gainesville, FL.
tional thoracotomy was required to repair ruptured intercostal
vessels. The “fatal triad” that had already occurred in this case led Background: Pain is one of the major prehospital symptoms in
to diffuse hemorrhage, which required tamponade of the pleural trauma patients and requires prompt management. Recent stud-
cavity. Marked swelling of the intrathoracic organs did not allow ies have reported insufficient analgesia after prehospital treat-
primary closure of the bony chest (Cave: compartment syndrome). ment in up to 43% of trauma patients, leaving significant room
Therefore, the thorax remained open and was closed only by a for improvement. Good evidence exists for prehospital use of oral
plastic sheet sewn into the skin (Bogota bag). After just 24 hours, transmucosal fentanyl citrate (OTFC) in the military setting. We
the tamponades could be removed and the chest definitively hypothesized that the use of OTFC for trauma patients in remote
closed. The nail-shot injury could already be treated primarily and challenging environment is feasible, efficient, safe, and might
with sternum cerclages. A postoperative cardiologic examination be an alternative to nasal and intravenous applications. Methods:
(echocardiography, transesophageal echocardiography) could not This observational cohort study examined 177 patients who were
detect an intracardiac lesion. Both patients were discharged with- treated with OTFC by emergency medical services (EMS) provid-
out any sequelae and are fit for work again. In cases of cardiac ers in three ski and bike resorts in Switzerland. All EMS provid-
injury with acute circulatory decompensation (pericardial tam- ers had previously been trained in administration of the drug and
ponade) and without timely assistance from a cardiac surgeon, handling of potential adverse events. Results: OTFC caused a sta-
drug-induced blockade of the AV-node with adenosine (chemical tistically significant and clinically relevant decrease in the level of
asystole) makes it possible to treat a cardiac wound even without pain by a median of 3 (IQR 2–4) in NRS (numeric rating scale)
extensive cardiac surgery experience. An immobilized heart can units (p<0.0001). Multiple linear regression analysis showed a
be more easily sutured over and inspected, especially to identify significant absolute reduction in pain, with no differences in all
an exit port on the posterior wall; otherwise, the necessary dislo- age groups and between genders. No major adverse events were
cation from the pericardium can lead to ventricular fibrillation. observed. Conclusions: Prehospital administration of OTFC is
safe, easy, and efficient for extrication and transport across all
This article has been published (citation: Pietsch U, Fischer H, age groups, genders, and types of injuries in alpine environments.
Rüst CA, et al. Oral transmucosal fentanyl citrate analgesia in Side-effects were few and mild. This could provide a valuable al-
prehospital trauma care: an observational cohort study. Scand J ternative in trauma patients with severe pain, without the delay of
Trauma Resusc Emerg Med. 2023;31(1):2. DOI:10.1186/s13049- inserting an intravenous line, especially in remote areas, where fast
023-01066-0). action and easy administration are important.

120 | JSOM Volume 23, Edition 4 / Winter 2023