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Objective-To evaluate the safety and efficacy of intranasal diamorphine as an analgesic for use in children in accident and emergency (A&E). Methods-A prospective, randomised clinical trial with consecutive recruitment of patients aged between 3 and 16 years with clinically suspected limb fractures. One group received 0.1 mglkg intranasal diamorphine, and the other group received 0.2 mgikg intramuscular morphine. At 0, 5, 10, 20, and 30 minutes pain scores, Glasgow coma score, and peripheral oxygen saturations were recorded; parental acceptability was assessed at 30 minutes.Results-58 children were recruited, with complete data collection in 51 (88%); the median summed decrease in pain score was better for intranasal diamorphine than intramuscular morphine (9 v 8), though this was not significant (P = 0.4, Mann-Whitney U test). The episode was recorded as "acceptable" in all parents whose child received intranasal diamorphine, compared with only 55% of parents in the intramuscular morphine group (P < 0.0001, Fisher's exact test). There was no incidence of decreased peripheral oxygen saturation or depression in the level of consciousness in any patient. Conclusions-Intranasal diamorphine is an effective, safe, and acceptable method of analgesia for children requiring opiates in the A&E department.

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Objective-To see if the alkalinisation of lignocaine caused a reduction in the pain of injection for digital nerve blockade. Methods-The study was a prospective randomised double blind study with each patient acting as their own control. During the study period, all patients aged 16 years and over presenting to the accident and emergency department with a condition requiring digital nerve blockade were considered for inclusion in the study. Each patient received an injection of both alkalinised and non-alkalinised lignocaine. The pain of each injection was then assessed on a visual analogue scale. Results-98 patients were entered in the study. The mean difference in pain scores between the non-alkalinised and alkalinised injections was 0.739, P < 0.001, 95% confidence interval 0.47 to 1 Several studies have shown that in healthy volunteers, raising the pH of lignocaine causes a significant reduction in the pain of injection'-'; however, these studies have all involved small patient numbers.Our aim was to see whether, in the setting of a busy A&E department, alkalinising lignocaine for digital nerve block is a practical proposition, and to confirm that it does indeed reduce the pain of infiltration. MethodsEthics approval was obtained from the Frenchay NHS Trust ethics committee. All patients aged 16 years and over, who required a digital nerve block, were included in the study.Written consent was obtained from all patients; patients with known hypersensitivity to lignocaine were excluded.The study was prospective, randomised, and double blind in design.For the purposes of the study 1% plain lignocaine BP was used. This is manufactured to a pH range of 4.0-5.5, although in the samples tested the pH range was 4.39-4.53.The lignocaine was alkalinised by adding 0.6 ml of 8.4% sodium bicarbonate to 4.4 ml of 1% lignocaine; this gave a measured pH of 7.38 to 7.51. Each patient was randomly assigned a trial pack which contained a 10 ml ampoule of lignocaine and two glass ampoules of diluent marked A and B. These had previously been prepared by the hospital pharmacy and had been randomised to contain either normal saline or 8.4% sodium bicarbonate.The test solutions were made up by drawing up 4.4 ml of lignocaine into a 5 ml syringe and then adding 0.6 ml of diluent A which had been drawn up using a 1.0 ml syringe to allow accurate measuring. The same procedure using a different pair of syringes was performed using diluent marked B.Each patient received an injection of both alkalinised lignocaine and non-alkalinised lignocaine. The order of injection and the side of injection were both randomised; patients with an even A&E number received the first injection on the radial side of the digit, whereas those with an odd A&E number received the first injection on the ulnar side. The lignocaine mixed with diluent A was always given first.Digital nerve block was then performed by slowly injecting 1.5 ml of the test solutions using a 25G needle either side of the digit at the level of the base of the proximal phalanx.Pa...