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Objectives: Although 50% nitrous oxide (N 2 O) and oxygen is a widely used treatment, its efficacy had never been evaluated in the prehospital setting. The objective of this study was to demonstrate the efficacy of premixed N 2 O and oxygen in patients with out-of-hospital moderate traumatic acute pain.Methods: This prospective, randomized, multicenter, double-blind trial enrolled patients with acute moderate pain (numeric rating scale [NRS] score between 4 and 6 out of 10) caused by trauma. Patients were assigned to receive either 50/50 N 2 O and oxygen 9 L/min (N 2 O group) or medical air (MA) 9 L/min (MA group), in ambulances from two nurse-staffed fire department centers. After the first 15 minutes, every patient received N 2 O and oxygen. The primary endpoint was pain relief at 15 minutes (T15), defined as a NRS 3 of 10. The NRS was measured every 5 minutes. Secondary endpoints were treatment safety and adverse events, time to analgesia, and patient and investigator satisfaction with analgesia.Results: Sixty patients were included with no differences between groups in age (median = 34 years, interquartile range [IQR] = 23 to 53 years), sex (37 males, 66%), and initial median NRS of 6 (IQR = 5 to 6). At T15, 67% of the patients in the N 2 O group had an NRS score of 3 or lower versus 27% of those in the MA group (delta = 40%, 95% confidence interval [CI] = 17% to 63%; p < 0.001). The median pain scores were lower in the N 2 O group at T15, 2 (IQR = 1 to 4) versus 5 (IQR = 3 to 6). There was a difference at 5 minutes that persisted at all subsequent time points. Four patients (one in the N 2 O group) experienced adverse events (nausea) during the protocol. 1 For a number of years, many rescue organizations throughout the world, including some employing caregivers not trained as emergency medical technicians, have made use of 50% nitrous oxide (N 2 O) and oxygen analgesia.2 There has been limited clinical evidence for the efficacy of this form of analgesia. N 2 O has a low solubility in blood and is not bound to blood proteins. It acts rapidly and is quickly reversible after inhalation is discontinued. A search of the literature identified 12 randomized controlled trials investigating the use of 50% N 2 O (compared with placebo or conventional analgesic regimens) in a range of conditions.

Jonas M, Caeiro JR, van der Veen AH, Roy P-M. for The FONDACAST Study Group. Comparison of fondaparinux with low molecular weight heparin for venous thromboembolism prevention in patients requiring rigid or semi-rigid immobilization for isolated non-surgical below-knee injury. J Thromb Haemost 2013; 11: 1833-43. Summary. Background:In several small studies, anticoagulant therapy reduced the incidence of venous thromboembolism (VTE) in patients with isolated lower-limb injuries. Objectives: To compare the efficacy and safety of fondaparinux 2.5 mg (1.5 mg in patients with a creatinine clearance between 30 and 50 mL min À1 ) over nadroparin 2850 anti-factor Xa IU.

Background Oligo-analgesia is common in the emergency department (ED). This study aimed at reporting, when initiated by triage nurse, the superior efficacy of inhaled methoxyflurane plus standard of care (m-SoC) analgesia versus placebo plus SoC (p-SoC) for moderate-to-severe trauma-related pain in the hospital ED. Methods A randomised, double-blind, placebo-controlled trial was conducted at eight EDs. Adults with pain score ≥4 (11-point numerical rate scale, NRS) at admission were randomised to receive one or two inhalers containing m-SoC or p-SoC. Primary outcome measure was time until pain relief ≤30 mm, assessed on the 100-mm Visual Analogic Scale (VAS). Results A total of 351 patients were analysed (178 m-SoC; 173 p-SoC). Median pain prior to first inhalation was 66 mm, 75% had severe pain (NRS 6–10). Median time to pain relief was 35 min [95% confidence interval (CI), 28–62] for m-SoC versus not reached in p-SoC (92 – not reached) [hazard ratio), 1.93 (1.43–2.60), P < 0.001]. Pain relief was most pronounced in the severe pain subgroup: hazard ratio, 2.5 (1.7–3.7). As SoC, 24 (7%) patients received weak opioids (6 versus 8%), 4 (1%) strong opioid and 44 (13%) escalated to weak or strong opioids (8 versus 17%, respectively, P = 0.02). Most adverse events were of mild (111/147) intensity. Conclusions In this study, we report that methoxyflurane, initiated at triage nurse as part of a multimodal analgesic approach, is effective in achieving pain relief for trauma patients. This effect was particularly pronounced in the severe pain subgroup.

Peritraumatic response and PTSD symptoms should be routinely assessed among parents whose child has experienced a traumatic event.