Development and domestication of a clinical guideline for pharmacological pain management of trauma patients in prehospital setting


1 Department of Health Services Management, Faculty of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran

2 Student Research Committee, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

3 Nursing and Midwifery Care Research Center, Isfahan, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

4 Department of Emergency Medicine, Emergency Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

5 Pre-hospital Emergency Organization and Emergency Medical Service Center, Babol University of Medical Science, Babol; Student Research Committee, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran


Introduction: Inadequate management of acute traumatic pain in the prehospital stage is a fact, which has many physical and mental adverse effects. No clinical guideline for the pain management of prehospital trauma patients in Iran has been published yet. Aims: This study aimed at development and domestication of a clinical guideline for pharmacological management of pain in prehospital trauma patients. Materials and Methods: A multistage evolutionary study method was used. First, a systematic review of articles, books, and guidelines for prehospital acute pain management with a comprehensive approach was carried out, then clinical guidelines with the most relevance to the topic were selected, and their quality was evaluated with AGREE tools. Finally, the initial guideline was developed based on the recommendations of the most comprehensive ones. The Delphi method and experts panel were used to summarize the information and finalize the clinical guidelines recommendations. Results: A total of 38 clinical guidelines and 150 related articles were found, of which five more comprehensive clinical guidelines and the most relevant topics were identified and reviewed. The recommendations that were agreed on by the Delphi stage were considered as the final recommendations, and others were reviewed again in the panel of experts by making the necessary changes. Finally, the domestic clinical guideline with 52 recommendations in three areas (general, assessment, and drug recommendations) was developed. Conclusions: Iran prehospital emergency organizations can use the recommendations of this clinical guideline to improve the quality of care, satisfaction, and protect patients' right.


1. Khankeh H, Alinia S, Masoumi G, Ranjbar M, Daddoost L, Hosseini S, et al. Prehospital services by focus on road traffic accidents: Assessment developed and developing countries. Journal of Health Promotion Management2013;2:71‑9. 
2. Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence of pain in emergency medical care. Am J Emerg Med 2002;20:165‑9. 
3. Berben SA, Meijs TH, van Dongen RT, van Vugt AB, Vloet LC, Mintjes‑de Groot JJ, et al. Pain prevalence and pain relief in trauma patients in the accident and emergency department. Injury 2008;39:578‑85. 
4. Liu M, Ferrante FM, Saunders Rait LW. Overview of Pain Mechanisms and Neuroanatomy. Pain management and regional anesthesia in trauma. London: WB Saunders; 2000. p. 29‑46. 
5. Chulay M, Burns S. AACN Essentials of Critical care Nursing Pocket Handbook. McGraw-Hill Medical; 2010. 
6. Ahmadi O, Isfahani MN, Feizi A. Comparing low‑dose intravenous ketamine‑midazolam with intravenous morphine with respect to pain control in patients with closed limb fracture. J Res Med Sci 2014;19:502‑8. 
7. Davari F, Isfahani MN, Rezvani M, Omidallah M, Pakravan F. Process management model in the emergency department of a university hospital: Reduction of patient waiting times by changes in human resources. J Res Med Dent Sci 2018;6:578‑85. 
8. Berben SA, Schoonhoven L, Meijs TH, van VugtAB, van Grunsven PM. Prevalence and relief of pain in trauma patients in emergency medical services. Clin J Pain 2011;27:587‑92. 
9. Weber A, Dwyer T, Mummery K. Morphine administration by paramedics: An application of the theory of planned behaviour. Injury 2012;43:1393‑6. 
10. Surgeons AA. Advanced Emergency Care and Transportation of the Sick and Injured. Jones and Bartlett Publishers; 2010. 
11. Ebben RH, Vloet LC, Verhofstad MH, Meijer S, Mintjes‑de Groot JA, van Achterberg T. Adherence to guidelines and protocols in the prehospital and emergency care setting: A systematic review. Scand J Trauma Resusc Emerg Med 2013;21:9. 
12. Anbari E, Yarmohammadian MH, Isfahani MN. From investigation of hospital protocols and guidelines to designing a generic protocol for responding to chemical, biological, radiological, and nuclear incidents. Int J Health Syst Disaster Manage 2015;3:195. 
13. Attia A. Adaptation of international evidence based clinical practice guidelines: The ADAPTE process. Middle East Fertility Society 2013;18:123‑6. 14. Masoudi Alavi N, Aboutalebi MS, Sadat Z. Pain management of trauma patients in the emergency department: A study in a public hospital in Iran. Int Emerg Nurs 2017;33:53‑8. 
15. Hadizadeh F, Kabiri P, Kelishadi R. Guideline for Development dan Adaptation of Clinical Practice Guidelines. Isfahan, Iran: Isfahan University of Medical Sciences. 2010:139. 
16. Officials National Association of State EMS. National Model EMS Clinical Guidelines. National Association of State EMS Officials; 2017. 
17. Gausche‑Hill M, Brown KM, Oliver ZJ, Sasson C, Dayan PS, Eschmann NM, et al. An evidence‑based guideline for prehospital analgesia in trauma. Prehosp Emerg Care 2014;18 Suppl 1:25‑34. 
18. Agree C. Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. The AGREE Collaboration; 2001. 
19. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839‑42. 
20. SchugSA, PalmerGM, ScottDA, HalliwellR, TrincaJ. Acute pain management: Scientific evidence, fourth edition, 2015. Med J Aust 2016;204:315‑7.