Original Contribution Nebulized fentanyl vs intravenous morphine for ED patients with acute limb pain: a randomized clinical trial Farahmand Shervin, MD a , Shiralizadeh Said, MD b , Talebian Mohammad-Taghi, MD a , Bagheri-Hariri Shahram, MD a, ⁎, Arbab Mona, MD a , Basirghafouri Hamed, MD c , Saeedi Morteza, MD a , Sedaghat Mojtaba, MD a , Mirzababai Habibolla, MD b a Tehran University of Medical Sciences, Tehran, Iran b AJA University of Medical Sciences, Tehran, Iran c Iran University of Medical Sciences, Tehran, Iran abstract article info Article history: Received 3 October 2013 Received in revised form 26 May 2014 Accepted 28 May 2014 Objective: Intravenous morphine has been used as a common method of pain control in emergency care. Nebulized fentanyl is also an effective temporary substitute. This study was designed to compare the effectiveness of nebulized fentanyl with intravenous (IV) morphine on management of acute limb pain. Methods: This was a placebo-controlled, double-blind randomized clinical trial. Ninety emergency department patients with moderate to severe pain aged 15 to 50 years were blocked randomized and enrolled in this study. Forty-seven patients in the experimental group received nebulized fentanyl (4 μg/kg) and IV normal saline as placebo, and the remaining 43 patients in the control group received IV morphine (0.1 mg/kg) and nebulized normal saline as placebo. All participants' pain scores were assessed by Numerical Rating Scale before and after intervention at 5-, 10-, 15-, 30-, 45-, and 60-minute intervals. Patients' vital sign and possible adverse effects were recorded respectively. Finally, all participants were assessed for their satisfaction. Results: The mean initial pain score in the experimental group was 8.7 and 8.4 in the control group (P = .1). Pain relief in both groups after 5 and 10 minutes were similar (P = .72). Although the pain relief was significantly greater with fentanyl at 15 minutes, this difference is not clinically significant. Pain management in both groups was successful and was more than 3 scores reduction in Numerical Rating Scale. Patient satisfaction in both groups was similar. No adverse effects were reported in the experimental group. Conclusion: This study suggests that nebulized fentanyl is a rapid, safe, and effective method for temporary control of acute limb pain in emergency department patients. © 2014 Elsevier Inc. All rights reserved 1. Introduction Most emergency visits, up to 70%, are due to patients seeking relief from pain [1]. Although the patient easily describes the pain, managing that pain in overcrowded emergency departments is truly challenging. It is desirable to use a rapid, effective, and safe analgesic immediately after triage. Although intravenous (IV) morphine has been used as a common method of pain control in most emergency departments [1], its administration requires the insertion of an IV cannula. This can cause additional distress to the patient and can often be time consuming or unsuccessful. Between 12% and 26% of IV catheter insertions are unsuccessful in adults [2]. As a result, temporary and feasible methods for analgesic administration have been recently considered. One such method, nebulized fentanyl is a convenient and effective temporary relief, which has not been fully studied in adult emergency departments [3–5]. Fentanyl is a highly potent opioid with considerable lipid solubility. These features make it an ideal opioid to be administered through inhalation [6]. In this study, the effect of nebulized fentanyl has been compared with the IV administration of morphine in patients with acute pain due to limb trauma in the emergency department of Imam Khomeini Complex Hospital. 2. Methods 2.1. Trial design This was a double-blind randomized clinical trial. 2.2. Participants A convenience eligible sample of 90 fully cooperative patients aged 15 to 50 years presenting to the emergency department due to limb trauma with acute pain with Numerical Rating Scale (NRS) score above 5 were enrolled in the study. The numeric verbal scale ranges from 0 to 10, from no pain to most pain. After obtaining a written American Journal of Emergency Medicine 32 (2014) 1011–1015 ⁎ Corresponding author. Emergency Department, Imam Khomeini Complex Hospital, Keshavarz Blvd, Tehran 1419733141, Iran. Tel./Fax: +98 21 66904848, +98 912 1324877 (cell). E-mail addresses: hariri@sina.tums.ac.ir, hariri.shahram@gmail.com (S. Bagheri-Hariri). http://dx.doi.org/10.1016/j.ajem.2014.05.051 0735-6757/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem