title: Nose and vein, speed and pain: comparing the use of intranasal diamorphine and intravenous morphine in a Scottish paediatric emergency department.
abstract: BACKGROUND
  Urgent analgesia is essential for all children who present in severe pain, but difficulties in obtaining venous access can delay the use of adequate opiate analgesia. Intranasal diamorphine (IND) is now in use in around 60% of emergency departments and is the preferred choice of analgesia as reported by both parents and healthcare professionals. While IND has similar efficacy to intramuscular morphine in children, no study has compared its use against the current gold standard, intravenous morphine (IVM).
  
  
  METHODS
  IND was introduced to the Royal Aberdeen Children's Hospital on 24 December 2009. A retrospective case series was constructed to compare its clinical performance with its predecessor IVM. Three unexplored factors were investigated: time to opiate analgesia, the requirement for further analgesia when still in the emergency department and the effect of simple coanalgesia (eg, paracetamol/ibuprofen) on these requirements.
  
  
  RESULTS
  297 patients were eligible for the study (147 IND, 150 IVM) over a 28-month period. There was a non-significant trend to a longer median time to administration of analgesia in patients receiving IND (p=0.170). Patients who received IND were less likely to require further analgesia (p<0.001). Both groups were less likely to require further analgesia when simple coanalgesia was given (p=0.049).
  
  
  CONCLUSIONS
  The authors found no significant difference in time to administration of analgesia between agents, but a learning curve has been identified. Sustained effort should be placed on the use of simple coanalgesia. The clinical performance of IND compares favourably with IVM in children with severe pain, and it remains an appropriate preferred agent.
authors.affiliation: ST6 Emergency Medicine, Emergency Department, Aberdeen Royal Infirmary, Aberdeen AB25 2ZD, UK. luke.regan@nhs.net
authors.forename: Luke
authors.initials: L
authors.lastname: Regan
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Chapman
authors.forename: Anna
authors.initials: A
authors.lastname: Celnik
authors.forename: Lesley
authors.initials: L
authors.lastname: Lumsden
authors.forename: Reem
authors.initials: R
authors.lastname: Al-Soufi
authors.forename: Nicola P
authors.initials: NP
authors.lastname: McCullough
mesh_terms: D000281:Administration, Intranasal; D000293:Adolescent; D000698:Analgesia / Q000379:methods*; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D004359:Drug Therapy, Combination; D004636:Emergency Service, Hospital; D005260:Female; D003932:Heroin / Q000008:administration & dosage*; D006801:Humans; D007223:Infant; D007275:Injections, Intravenous; D008297:Male; D009020:Morphine / Q000008:administration & dosage*; D010146:Pain / Q000517:prevention & control*; D012189:Retrospective Studies; D012606:Scotland; D013997:Time Factors
chemical_list: D000701:Analgesics, Opioid; D003932:Heroin; D009020:Morphine