Response to : Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department
1. Service Médical d'Urgence de la Brigade des Sapeurs Pompiers de Paris - France
2. Pôle Anesthesie - Réanimation - SAMU - Urgences Centre Hospitalo-Universitaire de Brest - France
3. Inserm U1018, Centre for research in Epidemiology and Population Health, Epidemiology of occupational and social determinants of health, Villejuif, France
4. Université de Versailles St-Quentin AP-HP, Poincaré University Hospital, Occupational health department/ EMS92 (SAMU92) , Garches, France
We read with interest the article written by Craig and al. (Emerg Med J, March 1, 2011) and we would like to make several remarks about it. The protocol chosen for the administration of morphine seems to us to be too different from common practice. The morphine must be titled, thus allowing a decrease in the frequency of its side effects. The authors should have performed a randomized, double-blind protocol by integrating the titration, which would have been more practical. On the other hand, it is not clear that other non-medicinal analgesic treatments were taken into account. Indeed, concerning patients already relieved by immobilization, the administration of morphine can express itself more readily by its side effects than by its analgesic action. Rescue analgesia was only administered if the "patient's pain relief was judged to be inadequate". A clearer redefinition of the term "inadequate" would be welcome given that a third of the patients were concerned. It would also have been important to determine the possible link between dissatisfaction and rescue analgesia. In the beginning of the discussion, the authors emphasize the similarity of the treatments, leading readers to believe that it was a study about equivalence, whereas it was actually a study about superiority. Concerning the statistical analysis, the author did not take into account repeated measures from the same individual. The sample size calculation, as well as the statistical analysis, seems to be inappropriate to us. In our extra-hospital activities, the objective is to reach a VAS < 40. This level was not reached in this study. The conclusion is the insufficient efficiency of both of the proposed protocols. The impact of this article on actual practice thus seems to us to be limited, despite the certain interest in the questions that are asked.
Conflict of Interest: