I

Volume 65 January 1972

Section of Anaesthetics
President
Major General K F Stephens CB OBE FFA RCS

Meeting January 8 1971

Entonox
Dr Peter J F Baskett
(UnitedBristol Hospitals and
Frenchay Hospital, Bristol)

virtually impossible. The high and stable oxygen

concentration in the mixture enables it to be used
safely and beneficially in the shocked patient.
Indeed, since a true 50 % inspired oxygen concenThe Use ofEntonox in the Ambulance Service
tration is achieved with the demand system, it is
Ambulance services throughout the country are likely that the oxygen therapy is as efficient as
now equipped with elaborate apparatus for conventional methods delivering pure oxygen
resuscitation butthe specific problem of pain relief from a continuous flow device. Bethune & Collis
in the accident situation seems to have been (1967) have shown that inspired oxygen concenlargely put on one side. There is no doubt that trations of more than 50% are rarely achieved
this is due to the shortcomings of what are con- with the commonly used masks.
sidered our mainstay analgesics in this country,
the opiate group. The respiratory and cardio- Precautions
vascular depression and the unreliable absorption A number of possible adverse effects must be conand excretion associated with these drugs are sidered when the introduction of Entonox into
accentuated in the accident and emergency situa- the ambulance service is contemplated. The main
tion. Add to this the difficulties of the Dangerous concerns are that the patient might become
Drugs Act regulations and the unfortunate and unconscious and lose his protective laryngeal
increasing addiction problems and it is obvious reflexes, or might become disorientated and uncothat the opiates are impossible to consider as a operative by entering the second stage of anessatisfactory analgesic in these conditions.
thesia. It was felt that self-administration using
There is nevertheless no doubt of the need for a the demand system provided an adequate safesafe, potent analgesic at the accident site. guard against these hazards. This is confirmed by
Ambulance men, very understandably, have been experience in domiciliary obstetrics where the gas
distressed at their impotence to relieve pain.
has been used by unsupervised midwives for many
years without accident. Similarly, the possibility
Suitability ofEntonox
of CO2 retention and narcosis occurring due to
Nitrous oxide is well known as a potent analgesic the administration of a high concentration of
sedative. Premixed in equal proportions with oxygen to a chronic bronchitic is avoided by
oxygen in a single cylinder (Entonox) it is remark- self-administration.
ably free from cardiovascular and respiratory
There is a theoretical danger of addiction to the
depression and other undesirable side-effects. The gas amongst the ambulance men. It was felt that
gas mixture is compatible with all known other this was a very unlikely possibility but neverthedrugs. The inhalational route of administration less the men were warned of this potential danger.
together with the physical properties of the gas
Entonox, while not inflammable, will support
ensure that there is a rapid onset of action and a combustion and should be used with caution
speedy recovery. Pain is quickly relieved, but the where there is a possibility of ignition.
vital physical signs and symptoms, essential to the
The constituents of the gas mixture tend to
examining casualty officer in hospital, return separate at temperatures below -6C. Such low
almost immediately after the administration is temperatures occasionally occur in this country
stopped. If the gas is administered by the patient and cylinders should not be stored in the open.
to himself using a demand apparatus, overdose is The men must be instructed in the method of

Proc. roy. Soc. Med. Volume 65 January 1972

reconstitution to the single gas phase by rewarm- who were too frightened to inhale deeply enough
ing and inversion of the cylinder (Bracken et al. to trip the demand valve. Only 2 patients failed to
1968).
master the technique. Some patients complained
of the smell of the black antistatic facemask. The
Practical Experience
optional transparent mask with a latex cuff is
Bearing these precautions in mind a pilot trial was more popular. A few patients preferred a mouthstarted in South Gloucestershire under the piece.
auspices of the Medical Officer of Health, Dr
In one-third of the cases the gas was used outAllan Withnell, in August 1969 (9 ambulances) side the ambulance to assist during lifting and
and extended to the whole county in March 1970 extraction of patients from the accident site.
(26 ambulances).
Training: An absolute essential is that the men are Conclusions
fully trained. No one was or is allowed to super- Dr Withnell and I have been impressed with the
vise administration of the gas until they have safety of the gas in the hands of ambulance men.
received full instruction. In a lecture and in prac- Not only is pain relief convincing but both
tical demonstrations they are taught the basic ambulance men and receiving casualty officers
properties, pharmacology, and action of Entonox, have remarked on the improvement in peripheral
the details of the-inhalational unit and the types circulation in many of the shocked cases, no doubt
of patient to whom the gas should be offered. The due to the combination of good analgesia and
principle of self-administration is especially em- oxygen therapy.
phasized. A tape recording together with 36 slides
REFERENCES
has been produced to reinforce training.
D W & Collis J M (1967) Anesthesia 22,43
Types of cases: The men were instructed to offer Bethune
Bracken A, Broughton G B & Hill D W (1968) Brit. med. J. iii, 715
the gas to any patient in pain. The choice as to
whether to accept the offer was entirely up to the
patient. The only contraindications which were
laid down were: head injuries with disorientation
or impairment of consciousness, maxillofacial Dr Geoffrey D Parbrook
injuries and cases of drunkenness. Table 1 shows (Department ofAnasthetics,
the number and variety of cases treated in the first Royal Infirmary, Glasgow C4)
year.
Results: All cases were carefully documented and Entonox for Post-operative Analgesia
the first 100 were followed up personally in The progress in the application of Entonox in the
hospital. Marked pain relief was obtained in 195 ambulance service (Baskett 1972) makes it particcases (64%); partial relief in 99 (33%Y.) and no ularly appropriate to reappraise the current use of
relief in 11 (3'5 Y); the assessment is necessarily Entonox in the post-operative period. Unlike the
subjective and a placebo effect must be situation in the ambulance service, narcotics are
acknowledged.
available for use post-operatively and the use of
No serious untoward side-effects occurred. Entonox must be justified by comparison to
There was drowsiness in 47(15 Y.), sleep in 6(2 %), morphine and related drugs.
amnesia in 5 (2%), nausea in 3 (1 Y.) and giddiFor moderate pain narcotics are cheap, easy to
ness in 3 (1 %). The incidence of nausea -is very administer and effective, but for severe pain such
low, indeed a number of patients found their as that after thoracic and abdominal operations
existing nausea relieved as the analgesia took narcotics are less effective and may increase the
effect.
risk of post-operative chest complications (Spence
Ninety-six per cent of the patients were able to et al. 1970). The side-effects of narcotics, such as
handle the apparatus correctly. This is a tribute to respiratory depression, cough suppression and
the good 'stretcher side' manner of the ambulance cardiovascular effects, are particularly undesirable
men. The unsatisfactory cases consisted of 4 and can be avoided if Entonox analgesia is suboctogenarians with fractured femurs, 3 children stituted in the immediate post-operative period.
under 5 years, and 2 patients with fractured ribs If pre-existing chronic respiratory disease is
present in these patients it gives an added reason
Table I
for avoidance of morphine and related drugs.
Cases treated with Entonox in the first year (total 305)
The major requirement for post-operative
No. of
analgesia is during the first one to two days
Condition
cases
Percentage
Trauma
151
50
(Parkhouse et al. 1961). Consequently, the duraAcute abdomen
57
19
tion of Entonox treatment lies within the limits
Obstetric
46
15
Myocardial infarction
set by potential marrow toxicity. Although this
25
8
Acute urinary retention
3
10
toxicity has been reported with four days' treatMiscellaneous
5
16
ment (Lassen et al. 1956), it is wiser to restrict