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Three Part Question

[In adults with anterior shoulder dislocation], [is Methoxyflurane better than Nitrous Oxide] [for relieving pain and ease of use.]

Clinical Scenario

A 40 year old male has been diagnosed with an anterior shoulder dislocation following a fall. Is inhaled Methoxyflurane a safer, more practical and efficacious drug to use for pain control before and during the reduction when compared to nitrous oxide?

Search Strategy

A computer generated search was conducted in May 2018 using Medline and CINAHL.


Medline (Ovid) 1946- May week 3 2018 (((((((dislocation, shoulder[MeSH Terms]) OR shoulder dislocation*) OR trauma) AND methoxyflurane) OR penthrox) AND nitrous oxide)) AND emergency

CINAHL: 2009- 2017 (((((((dislocation, shoulder[MeSH Terms]) OR shoulder dislocation*) OR trauma) AND methoxyflurane) OR penthrox) AND nitrous oxide)) AND emergency

Search Outcome

Medline
1 paper identified, a systematic review dated from database inception to December 22, 2015. Both studies in the systematic review compared Methoxyflurane to a Placebo and were therefore irrelevant to this search.

Results
CINAHL
190 citations were identified. Of these papers, none directly compared Nitrous Oxide to Methoxyflurane with shoulder dislocation in the ED and were therefore found to be irrelevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

No papers found comparing Nitrous Oxide to Methoxyflurane in pain relief for shoulder dislocation in the ED. Further ED studies are needed to explore.

Clinical Bottom Line

On review of Methoxyflurane versus Placebo in Trauma pain and Nitrous Oxide versus Placebo in Trauma pain, both provide well-tolerated pain relief. The ease of administration and easy access to Methoxyflurane (light, inhaler device) may be advantageous over Nitrous Oxide from a practical viewpoint.

References

1. Porter KM, Siddiqui MK, Sharma I et al. Management of trauma pain in the emergency setting: low-dose methoxyflurane or nitrous oxide? A systematic review and indirect treatment comparison. Journal of Pain Research 2018:11 11-21.
2. Coffey F, Wright J, Hartshorn S et al. STOP!: a randomised, double-blind, placebo-controlled study of the efficacy and safety of methoxyflurane for the treatment of acute pain. Emerg Med J. 2014 Aug;31(8):613-8.
3. Coffey F, Dissman P, Mirza K et al. Methoxyflurane Analgesia in Adult Patients in the Emergency Department: A Subgroup Analysis of a randomised, double-blind, placebo-controlled study (STOP!) Adv Ther 2016 Nov;33(11):2012-2031.