Report by Mark Davies, Specialist Registrar Search checked by Ian Crawford, Clinical Research Fellow

Clinical scenario An 8 year old boy attends the emergency department after a fall at school. Clinically he has a displaced fracture of the right radius and ulna. He is in a lot of pain and so needs analgesia before radiography. You have heard of the use of nasal diamorphine for pain relief but wonder whether there is evidence to show whether it is as effective as injected morphine.

Three part question [In children with acute pain] is [nasal diamorphine or injected morphine] better at [providing safe, acceptable and effective analgesia].

Search strategy Medline 1966–01/01 using the OVID interface. [(exp heroin OR diamorphine.mp OR exp narcotics OR opioids.mp OR opiates.mp OR narcotics.mp) AND (exp nasal mucosa OR nasal.mp OR exp nose OR nose.mp OR exp administration, intranasal OR intranasal.mp)].

Search outcome Altogether 303 papers found of which only one was relevant. An additional paper has recently been published and was not indexed on Medline at the time of searching. These two papers are shown in table 2. Table 2

Comments These two papers would suggest that intranasal diamorphine is as effective as intramuscular morphine and is much better tolerated by children with no apparent increased risk of side effects. Further work comparing intranasal diamorphine with oral morphine would be useful.

Clinical bottom line Nasal diamorphine is a safe and effective analgesic in children with acute musculoskeletal pain and is to be recommended.

Report by Mark Davies, Specialist Registrar Search checked by Ian Crawford, Clinical Research Fellow