Review Article

Acute Pain in the African Prehospital Setting: A Scoping Review

Table 2

Overview of included studies.

Author(s), year of publicationStudy designStudy aim(s)Study settingData collection periodStudy sampleResults
Pain assessment (initial and reassess)Nonpharmacological managementPharmacological management

Mulder, 2012 [40]Mixed methods: sequential exploratoryTo determine the factors contributing to the clinical decision-making process made by South African paramedics in their management of patients with acute traumatic painSouth AfricaPhase 1: quantitative (descriptive cross-sectional study)
7 June–30 September 2010 participants (ALS), 22% response rateInitial: analgesia initiated based on a comprehensive clinical picture
Reassess: both decreased pain score and physiological indicator of change
Positioning and splintingMorphine, ketamine, voltaren, NSAIDs, tramadol, benzodiazepines
Phase 2: qualitative (in-depth interviews)
2010 participants (ALS)Initial: main determinant in decision-making around initiating analgesia was the patient’s expression (verbal) of pain
Reassess: participants rely on the patient’s expression of pain relief rather than a numerical score in the decision-making process
Not reportedMorphine or ketamine (preferred when in scope) or alternatively a combination of morphine and ketamine

Matthews et al., 2017 [41]Descriptive retrospective surveyTo describe prehospital pharmacological analgesia practices in the city of Cape TownCape Town, South AfricaAugust 2013–July 2014530 PCRs (ALS employees of WCEMS)Initial: NRS assessed in 21% () of PCRs
Reassess: 2nd NRS assessed in 6% () of PCRs
Not reportedNitrates administered in 37% (), morphine in 75% (), and ketamine in 1.7% () of cases

Vincent-Lambert and De Kock, 2015 [42]Prospective descriptive study: internet-based surveyTo describe the use of morphine sulphate and compare paramedic practices to existing guidelines and literatureSouth AfricaOne month in 2015 participants (ALS), 38% response rateInitial: not reported
Reassess: stop pain management partly based on decreased pain score
Not reportedMorphine

Cox et al., 2015 [43]Descriptive cross-sectional studyTo assess the community management of paediatric burns prior to admission to a burns centre against the current provincial policy guidelines and to identify areas for improvementCape Town, South AfricaAugust–October 2012 and June–August 2013 paediatric burn patients (aged 1 month to 14 years)Initial: not performed
Reassess: not performed
Cooling with water, ice or cooling agents like Burnshield®
Burnshield® applied by EMS in 6.2% () children
Paracetamol, NSAID, tilidine, morphine, and ketamine

HPCSA, 2018 [44]Adaptive CPG designTo review and update existing protocols for ECPs and create an evidence-based CPG which provides an evidence base for emergency care practice contextualised to the South African setting, is patient-centred, realistic, and enhances continuity of care throughout the emergency system, and is aligned to best practice and provide guidance to current practitioners and those envisioned by the draft NECET policySouth AfricaSearching: October 2015–January 2016276 CPGs includedInitial: assess pain as part of general patient care
Reassess: use age-appropriate pain assessment scale, reassess every 5 minutes
Observe for evidence of serious adverse effects
Burns: cool and cover burns
Fracture: effectively immobilise fracture
No further recommendation specifically related to nonpharmacological pain management
Labour: inhaled nitrous oxide or opioids (IV or IM)
Chest pain (dependent on the cause): sublingual or IV nitrates and/or opioids (IV or IM)
Burns: paracetamol or NSAIDs, consider opioids for intermittent or procedural pain
Trauma: narcotic analgesics (morphine IV or fentanyl IV/IN) for moderate to severe pain
Procedural sedation and analgesia: ketamine: IV, if sedation inadequate, incremental IV doses
Postresuscitation care: pain and discomfort should be controlled with analgesics and sedatives

Scott et al., 2017 [45]Quasi-experimental: interrupted time series analysisTo compared five quality process measures recorded before and after the implementation of the CQI programme and aimed to determine the immediate impact of the CQI programme as well as the impact over timeKigali, RwandaPre-CQI: January 2013–February 2014
Post-CQI: April 2014–May 2015
trauma patients >15 yearsInitial: not reported
Reassess: not reported
Splinting of long bone fractures:
Pre-CQI: 87.5% ()
Post-CQI: 92.6% ()
value: 0.019
Acetaminophen, ibuprofen, diclofenac, morphine, tramadol, fentanyl, pethidine and ketamine.
Pain management for long bone fractures:
pre-CQI: 85.1% ()
Post-CQI: 93.6% ()
value: <0.001

No formal prehospital care-certified programme was available, and thus, ambulances in Rwanda are manned by one driver, one anaesthesia technician, and one nurse. ALS: advanced life support; CPGs: clinical practice guidelines; CQI: continuous quality improvement; ECPs: emergency care providers; EMS: emergency medical services; IM: intramuscular; IN: intranasal; IV: intravenous; NECET: National Emergency Care Education and Training; NRS: numeric rating scale.