{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T12:10:13Z","timestamp":1784549413996,"version":"3.55.0"},"reference-count":109,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:00:00Z","timestamp":1782864000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000664","name":"Health Technology Assessment programme","doi-asserted-by":"publisher","award":["NIHR128086"],"award-info":[{"award-number":["NIHR128086"]}],"id":[{"id":"10.13039\/501100000664","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journalslibrary.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["Health Technol Assess"],"abstract":"<jats:sec id=\"abs1-1\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Paramedics frequently administer analgesic medications for pain following trauma. Morphine is the most commonly administered strong analgesic. However, it may not be the best option as it may lower blood pressure, depress respiration and there is a risk of dependency. Ketamine might be a better option. We sought to compare clinical and cost-effectiveness of paramedic administered ketamine and morphine in patients with severe pain following trauma.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-2\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>PACKMaN was a double-blinded, randomised controlled, superiority trial. Eligible patients were 16 years of age or over, had an acute injury, and articulated a pain score of 7 or greater on a 0\u201310 numeric rating score. We excluded pregnant patients, prisoners, those unable to articulate a pain score and anyone lacking capacity. The maximum dose of morphine was 20\u00a0mg while the maximum dose of ketamine was 30\u00a0mg. The trial drug was titrated to effect. The primary outcome was the Sum of Pain Intensity Difference score.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-3\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      We randomised 449 participants: 219 (49%) received ketamine and 230 (51%) received morphine. The Sum of Pain Intensity Difference score was 3.5 (standard deviation 2.8) for ketamine and 3.4 (standard deviation 3.0) for morphine. We found no significant difference in efficacy between drugs (adjusted mean difference 0.1, 95% confidence interval \u22120.4 to 0.6;\n                      <jats:italic>p<\/jats:italic>\n                      \u2005=\u20050.7). Ketamine was more likely to achieve \u2018very much improvement\u2019 (odds ratio 1.58, 95% confidence interval 1.08 to 2.31;\n                      <jats:italic>p<\/jats:italic>\n                      \u2005=\u20050.019) and to do so more rapidly than morphine (hazard ratio 1.42, 95% confidence interval 1.09 to 1.84;\n                      <jats:italic>p<\/jats:italic>\n                      \u2005=\u20050.009). However, morphine was likely to last longer than ketamine (hazard ratio 1.28, 95% confidence interval 1.05 to 1.56;\n                      <jats:italic>p<\/jats:italic>\n                      \u2005=\u20050.013). There was no evidence of a significant difference in serious adverse events.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-4\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Ketamine does not provide superior analgesia than morphine when treating acute severe trauma pain. Ketamine is a suitable alternative that is safe for use by paramedics.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-5\">\n                    <jats:title>Limitations<\/jats:title>\n                    <jats:p>Patients were required to provide verbal assent to participate, consequently we were only able to recruit patients who had capacity to understand what was being asked of them. It is also therefore probable that we were unable to recruit the most severely injured patients. These factors may limit generalisability of our results. Furthermore, we were unable to complete a planned sensitivity analysis to determine if there was a difference in treatment response between patients with more minor injuries and those who were more severely injured. Finally, we experienced a loss to follow-up at 3 and 6 months, so our findings for long term outcomes may have been underpowered.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-6\">\n                    <jats:title>Future work<\/jats:title>\n                    <jats:p>Future research should focus on identification of the optimal drug (or combination of drugs), dosing and drug route to achieve rapid control of pain. In addition, it would be valuable to explore the relationship between paramedic analgesia and the development of chronic pain.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"abs1-7\">\n                    <jats:title>Funding<\/jats:title>\n                    <jats:p>This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128086.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3310\/kgto6391","type":"journal-article","created":{"date-parts":[[2025,8,19]],"date-time":"2025-08-19T10:45:54Z","timestamp":1755600354000},"page":"1-32","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Paramedic analgesia comparing ketamine and morphine in trauma. A synopsis of the PACKMaN double-blind RCT"],"prefix":"10.3310","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0220-2223","authenticated-orcid":true,"given":"Michael A","family":"Smyth","sequence":"first","affiliation":[{"name":"Clinical Trials Unit, University of Warwick, Coventry, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-8926-3479","authenticated-orcid":true,"given":"Hannah","family":"Noordali","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, University of Warwick, Coventry, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1737-2866","authenticated-orcid":true,"given":"Ranjit","family":"Lall","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, University of Warwick, Coventry, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-6903-7637","authenticated-orcid":true,"given":"Felix","family":"Michelet","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, University of Warwick, Coventry, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3121-6050","authenticated-orcid":true,"given":"Stavros","family":"Petrou","sequence":"additional","affiliation":[{"name":"Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4322-9695","authenticated-orcid":true,"given":"Kamran","family":"Khan","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, University of Warwick, Coventry, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2950-4758","authenticated-orcid":true,"given":"Joyce","family":"Yeung","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, University of Warwick, Coventry, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8532-3500","authenticated-orcid":true,"given":"Gordon","family":"Fuller","sequence":"additional","affiliation":[{"name":"School of Medicine and Population Health, University of Sheffield, Sheffield, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-9235-2676","authenticated-orcid":true,"given":"Alison","family":"Walker","sequence":"additional","affiliation":[{"name":"West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, West Midlands, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7320-4205","authenticated-orcid":true,"given":"Rebecca","family":"McLaren","sequence":"additional","affiliation":[{"name":"Yorkshire Ambulance Service NHS Trust, Springhill, Wakefield, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7432-4188","authenticated-orcid":true,"given":"Duncan","family":"Buckley","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, University of Warwick, Coventry, England"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3356-7751","authenticated-orcid":true,"given":"Kath","family":"Starr","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, University of Warwick, Coventry, 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