Oral transmucosal fentanyl citrate analgesia in prehospital trauma care: a retrospective observational cohort study focusing on age and gender differences.

Introduction
Effective pain management is essential in trauma care, as it reduces suffering and prevents long-term complications. However, prehospital analgesia is often inadequate, particularly in challenging environments such as alpine rescue settings, where establishing intravenous access can be difficult. Oral transmucosal fentanyl citrate (OTFC) offers a fast-acting, needle-free alternative, but has rarely been studied in civilian prehospital settings, particularly among paediatric and elderly populations. This study aimed to evaluate the feasibility, effectiveness and safety of OTFC for prehospital analgesia in a civilian mountain rescue context, covering all age and sex groups.Methods
This retrospective observational cohort study included all trauma patients treated with oral transmucosal fentanyl citrate (OTFC). Patients experiencing severe pain (NRS ≥ 4) and lacking intravenous access were eligible. OTFC was administered by trained emergency medical services providers. Data on demographics, pain scores and adverse events were prospectively recorded using a standardised digital protocol. The primary outcome was pain reduction, as measured by the Numeric Rating Scale (NRS); safety was assessed by recording adverse events. Statistical analysis included paired and unpaired tests, ANOVA and non-parametric equivalents, as appropriate. Significance was set at p < 0.05.Results
A total of 365 patients (60.5% male, mean age of 37 ± 18 years) were included in the study. The majority sustained extremity injuries, and the median initial pain score was 8 (IQR 6-8). Following OTFC administration, a significant median reduction of two NRS units (IQR1-3) was observed, corresponding to a mean relative reduction of 32% ± 22%. Pain reduction was consistent across all age and sex groups. In children and adolescents (6-16 years), the median reduction was 3 NRS points (relative reduction 34%), while in adults (> 16 years), it was 2 points (31% relative reduction). No significant differences in analgesic efficacy were found between subgroups based on age or sex. No serious adverse events, such as respiratory depression or the need for naloxone, were reported.Conclusion
OTFC is a safe, effective and practical analgesic for use in prehospital trauma care, especially in remote mountainous areas. Its consistent performance across age and sex groups, needle-free administration and low side-effect profile make it a valuable option where intravenous access is limited.