VCOM Carolinas Research Day 2023

Clinical Studies

Emergency Medical Technicians (EMT’s) Can Administer Nitrous Oxide for Effective Analgesia in an Urban Multi-Tiered EMS System. Emiliano Costilla, MS-I, NRP, Bradley Teasley, OMS-II, NREMT , Mirinda Ann Gormley, PhD, MSPH, NRP, Martin Lutz, MD, Michael Troise, MD, Xingpei Zhao, MSPH, Thomas Blackwell, MD, Stella Self, PhD, Matthew Cobb, MD, Daniel Schwerin, MD Greenville County EMS (GCEMS), Greenville SC Prisma Health Department of Emergency Medicine, Greenville SC VCOM-CC, Spartanburg SC Abstract Results

Abstract # CLIN-4

Figure 1: Forest Plot of Odds Ratio With 95% CI for Responding Improvement to Treatment Figure 1 plots the odds ratio (OR) and 95% confidence interval (CI) for the associations between the patients' response and the covariates. Compared to all others, those patients who self-dosed nitrous oxide and received parenteral

Figure 1 : flowchart of patients encountered

Background : National Highway Traffic Safety Administration guidelines do not include nitrous oxide (N 2 O) administration in the scope of practice for emergency medical technicians (EMTs), instead recommending N 2 O administration for the paramedic scope of practice. 1 Perhaps a cohort of properly-trained EMTs could safely supervise N 2 O self-dosing for patients in pain. Objective : To observe the safety and efficacy of self-dosed nitrous oxide when administered by properly-trained EMTs.

analgesia (n=11, 6.4%) had 87.6% lower odds (p<0.01) of demonstrating an improved response to any pharmacologic attempt at analgesia; additionally, for every 1 hour increase in pain duration, the odds of reporting improvement with treatment decrease by 1.5%.




Incidents eligible for electronic health record (EHR) review: potential for N 2 O use: 176

Population: GCEMS 911 patient encounters Inclusion: N 2 O unit opened by crew


N = 171 Improved Unchanged Worse/NA Figure 2 : GCEMS pain protocol Table 1: Improved Responses: Chi Square analysis

• GCEMS documented ZERO adverse events in all 176 patients • N 2 O effected an improved response in nearly 3 of 4 patients, and only 14 patients (8.1%) needed a paramedic; 11 of those received meds other than N 2 O from their paramedic. • Failing N 2 O increased the chance of failing IV/IO/IM meds • The analgesic strength of self-dosed N 2 O (and IV/IO/IM meds) are inversely proportional to the length of time of a patient’s complaint of “pain.” EMTs could initiate and supervise self-dosing of N 2 O without paramedic attendance for relief of both medical and traumatic pain in out-of-hospital patients. Local agencies may consider adopting nitrous oxide programs for out-of hospital analgesia. State officials are expanding the EMT scope of practice to include self-administration of N 2 O.

N 2 O self-dosing initiated and supervised by an EMT crew (100% transported to ED): 171

• Failure of unit (2) • Other (2) • Paramedic present (1)

(-) 5

N2O Administered 125 (73.1%)

41 (24.0%)

5 (2.9%)

Chi Square

Statistical Analysis: Paired t-tests assessed the differences in NPRS secondary to inhalation. T-tests were stratified by pain type (traumatic and non traumatic). Associations between demographic and clinical characteristics and patient improvement following all treatments are the result of multivariate logistic regression (odds ratios and 95% confidence interval included).

Response to N2O self-dosing • Lead EMT impressions (categorical variable): o Improved o Unchanged o Worsened • Pain scores (verbal numeric rating score; VNRS; 1-10) o VNRS immediately before N 2 O self-dosing o VNRS 5 minutes in N 2 O self-dosing o VNRS reported during transfer of care

Adverse Events




NPRS (time = 0 m) 9.30 (1.22*) 8.95 (1.69*)

9.40 (1.35*)


NPRS (time = 5 m) 6.30 (2.41*) 8.70 (1.90*) NPRS (ED triage) 5.85 (2.83*) 8.71 (1.90*) <0.01 * Standard deviation Table 2: Improved Responses: Odds Ratio and 95% Confidence Intervals Upper Limit ‰‡ ͳǤͲͲ ͲǤͻͺ ͳǤͲʹ ͲǤ͹ʹ ȋ–‹‡ α ͲȌ ͳǤͳ͸ ͲǤͺͺ ͳǤͷʹ ͲǤ͵ͳ ƒ‹ —”ƒ–‹‘ ‹‡ ͲǤͻͻ 0.98 1.00 0.04 ‡†‡” ȋ”‡ˆα ƒŽ‡Ȍ ͳǤͲͳ ͲǤͶ͵ ʹǤ͵ͻ ͲǤͻͻ ƒ‹ ›’‡ ȋ”‡ˆα ‡†‹…ƒŽȀ Š”‘‹…Ȍ ͳǤ͸Ͳ ͲǤͷͶ ͶǤ͹ͳ ͲǤͶͲ Š‡–Š‡” ”‡“—‡•–‡† ͲǤͳʹ 0.03 0.47 <0.01 N/A N/A <0.01 Effect Odds Ratios 95% Confidence Intervals (CI) - value Lower Limit


1. National Highway Traffic Safety Administration. Scope of practice model. nd%20_2_August_2021.pdf

Did the patient need a paramedic? • Invasive route of administration (IV/IO/IM)

Greenville County EMS would like to thank Henry Schein for their generous donation of six Nitronox units at the birth of this project. Acknowledgements

o Fentanyl – standing orders up to 200 mcg o Morphine – standing orders up to 10 mg o Ketamine – standing orders up to 30 mg o Ketorolac – standing orders up to 15/30 mg

• Cardiac monitoring

This project is EXEMPT FROM IRB REVIEW according to federal regulations.


2 0 2 3 R e s e a r c h R e c o g n i t i o n D a y

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