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Written by

Published 1 January 0001

Key learning points

  • Inadequate assessment and management of acute pain remains common in both the prehospital and Emergency Department (ED) setting.
  • There is a need for a well tolerated and effective analgesia with a rapid onset of action and prolonged duration of action.
  • Methoxyflurane has been shown to be a fast-acting, effective analgesic in patients in the prehospital setting with moderate pain due to acute trauma.


Despite advances in pain medication and guidelines for the treatment of pain such as the World Health Organization’s (WHO) analgesic ladder,1 inadequate assessment and management of acute pain remains common in both the prehospital and Emergency Department (ED) setting. Studies have shown that the prevalence of pain is up to 90% in the ED2,3 and many patients are undertreated.4,5,6

There is a need for effective analgesia with a rapid onset of action and extended duration of action, especially in the prehospital setting. At competitive sports events, there is often a lack of close patient monitoring and availability of controlled drugs until the arrival of the ambulance service or air ambulance crew. Additionally, the drug and mode of application should be well-tolerated by the athlete, simple to use by the treating medical team and, ideally, should not interfere with anti-doping regulations of national or international governing bodies.

Case report

This report describes the case of a 29-year-old female rider, who had competed at an equestrian event and was thrown off her horse during the cross country event. In doing so, she fell onto her outstretched left hand and sustained a sprain injury.

On examination, there was considerable soft tissue swelling of the wrist with local tenderness over the distal radius but no angulation or palpable displacement. The distal neurovascular supply appeared intact and there were no apparent injuries to the rest of the left upper limb. On inspection of her helmet there was evidence of some skid marks and she did report hitting her head on the muddy ground and feeling a little dizzy. After completing the physical examination there was suspicion of a minor concussion, some tenderness over the left hemithorax with no apparent bruising or rib fracture and a possible non-displaced fracture of the left distal radius. On further enquiry, the injured rider reported a pain score of 7 out of 10 on the visual analogue scale (VAS).7

The injured wrist was splinted and a cool pack was applied, reducing the VAS score to 5. The local ambulance service was contacted, with an estimated time of arrival of approximately 16 minutes due to the rural location. As there was no access to opiates, the decision was taken to supply methoxyflurane via a Penthrox®▼ inhaler. After about eight inhalations the injured rider reported the onset of pain relief with a marked reduction in VAS score to 2 after five minutes and to 1 at 10 minutes.

On arrival of the ambulance service, she was virtually painfree and could be transferred to the nearest ED for further management. It transpired that she had sprained her left wrist and suffered a minor head injury for which she did not need further hospital observation.


This case illustrates the benefits of methoxyflurane in the prehospital trauma setting where access to drugs and monitoring is limited. Methoxyflurane has been shown to be a fast-acting, effective analgesic in patients with moderate pain from acute trauma in the ED setting.8,9 Due to the lack of opiates in the reported setting, methoxyflurane was initially intended as a bridging agent until the arrival of the ambulance service, when stronger analgesics would be available.

However, in a patient with suspected concussion, any pain medication that interferes with the level of consciousness or that produces side effects such as nausea and vomiting would interfere with subsequent head injury observations. In addition, there was evidence of a thoracic contusion, so that a rib fracture or small pneumothorax could not be excluded before arrival at hospital. Therefore, the use of nitrous oxide was also contraindicated and as a result, methoxyflurane was the most suitable alternative in the described setting.

  • Dr Patrick D Dissmann is a consultant in Emergency Medicine, Sports & Exercise Medicine and Pre-hospital Care and clinical director, Emergency Department, Klinikum Lippe GmbH, Detmold, Germany

  • Disclaimer
    The treatment options described in this case scenario are based on the global literature and the long clinical experience of the author. Not all the medications listed are licensed for use in the settings described and physicians should consult the relevant SPCs prior to prescribing.


  1. Ventafridda V, Saita L, et al. International Journal of Tissue Reactions 1985;7:93–96.
  2. Cordell WH, Keene KK, et al. American Journal of Emergency Medicine 2002;20:165–169.
  3. Berben SA, Meijs TH, et al. Injury 2008;39:578–585.
  4. Pierik JG, IJzerman MJ, et al. Pain Medicine 2015;16:970–984.
  5. Guéant S, Taleb A, et al. European Journal of Anaesthesiology 2011;28:97–105.
  6. Dale J, Bjørnsen LP. Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 2015;23:86.
  7. Lord BA, Parsell B. Prehospital and Disaster Medicine 2003;18:353–358.
  8. Coffey F, Wright J, et al. Emergency Medicine Journal 2014;31:613–618 .
  9. Coffey F, Dissmann P, et al. Advances in Therapy 2016;33:2012–2031 .

Date of preparation: April 2017; MINT/PAEU-17018