Emerg Med J 30:49-52 doi:10.1136/emermed-2011-200970
  • Original articles

Nose and vein, speed and pain: comparing the use of intranasal diamorphine and intravenous morphine in a Scottish paediatric emergency department

  1. Nicola P McCullough1
  1. 1Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
  2. 2Raigmore Hospital, Inverness, UK
  3. 3Paediatric Emergency Medicine Department, Royal Aberdeen Children's Hospital, Aberdeen, UK
  1. Correspondence to Dr Luke Regan, ST6 Emergency Medicine, Emergency Department, Aberdeen Royal Infirmary, Aberdeen AB25 2ZD, UK; luke.regan{at}
  1. Contributors LR: concept, data analysis, article preparation. ARC: data collection, data analysis, article preparation. AC: data collection, data analysis. LL, RA-S and NPM: data collection.

  • Accepted 26 January 2012
  • Published Online First 12 March 2012


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).

Conclusion 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.


  • Guidelines: This manuscript adheres to guidelines for reporting the results of case series as proposed by EQUATOR and as available in the following paper: Kempen JH. Appropriate use and reporting of uncontrolled case series in the medical literature. Am J Ophthalmol 2011;151:7–10.e1. PMID: 21163373.

  • Competing interests None.

  • Ethics approval This project is a retrospective consecutive case series, auditing the management of pain relief in children using two different methods of analgesia—as such, no formal ethical approval was required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Raw data are available on request alongside evidence of statistical analysis.

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Among patients with minor TBI (GCS 13-15) getting CT scans ≥ 24 hours after injury, what proportion have a traumatic finding?


0.5% - 43% response rate
3% - 41% response rate
10% - 16% response rate

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