Abstract
To the Editor:
We thank Drs Yilmaz, Tatliparmak, and Ak for the insightful comments and further discussion 1 prompted by our article “Time to Reconsider Analgesia in Mass Casualty Incidents.” 2 Having recently faced a disaster of epic proportions, their experience and understanding of these incidents is extremely valuable. Our paper advocates for early analgesia, since this has been traditionally reserved for later stages in the management of patients in mass casualty incidents (MCI). With currently available drugs and proper training, we truly believe that patients can benefit from early and effective analgesia.
Including simple treatment or therapeutic elements to triage is not new, and many triage tools include some types of interventions such as opening the airway. 3 Given recent events, particularly incidents involving terrorism and mass shootings, there has been a heightened focus on bleeding control. 4 More recent triage tools, such as the Ten Second Triage, address this concern with an emphasis on hemorrhage control in the second step of the triage algorithm, suggesting the use of “pressure, tourniquet, and packing.” 5 Implementing simple analgesia at the end of a triage tool, as suggested by Dr Yilmaz et al through the acronym START-A (simple triage, rapid treatment, and analgesia), could allow for early analgesia, with limited additional time added to triage. The therapeutic options suggested in our article, such as fentanyl lozenges and methoxyflurane inhalers, take only a few seconds to be delivered, avoiding the time-consuming task of intravenous cannula insertion and medication titration. However, increasing the number of steps in atriage tool increases its complexity and may reduce adherence and its use in a real-world event. What has been noticed is a tendency to simplify triage tools in recent years, and introducing an extra term would deviate from that trend. However, it could prove beneficial in avoiding the omission of analgesia from early care. Training with and implementing a triage tool of this kind would allow emergency response services to strategize in advance on how to administer early analgesia to patients. As with all new interventions in medicine, the START-A triage would need to be evaluated to test its usefulness and effectiveness and the extended time needed to administer analgesia. Comparing it head-on against the traditional START triage tool would be valuable, and the time to first analgesic administration could be an interesting outcome to test and measure.
Advocating for early analgesia, usually reserved for later stages of the management of MCIs, we firmly believe that timely administration is achievable and can significantly benefit patients. Triage remains essential in managing MCIs, and while each tool has inherent limitations, a coherent integration with subsequent care allows for swift and effective treatment. The proposed START-A triage tool, incorporating analgesia, presents a potential improvement for early pain management. Despite possibly increasing the complexity of early triage, addressing analgesia rapidly in this complex environment is crucial, and its implementation warrants evaluation to assess its practicality and impact on time to first analgesic administration.