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Background  Sufficient analgesia is an obligation, but oligoanalgesia (NRS> 3) is frequently observed prehospitally. Potent analgesics may cause severe adverse events. Thus, analgesia in the helicopter emergency medical service (HEMS) setting is challenging. Adequacy, efficacy and administration safety of potent analgesics pertaining to injured patients in HEMS were analysed.    Methods  Observational study evaluating data from 14 year-round physician-staffed helicopter bases in Austria in a 12-year timeframe.    Results  Overall, 47,985 (34.3%) patients received analgesics, 26,059 of whom were adult patients, injured and not mechanically ventilated on site. Main drugs administered were opioids ( n =20,051; 76.9%), esketamine ( n =9082; 34.9%), metamizole ( n =798; 3.1%) and NSAIDs ( n =483; 1.9%). Monotherapy with opioids or esketamine was the most common regimen ( n =21,743; 83.4%), while opioids together with esketamine ( n = 3591; 13.8%) or metamizole ( n =369; 1.4%) were the most common combinations. Females received opioids less frequently than did males ( n =6038; 74.5% vs.  n =14,013; 78.1%;  p < 0.001). Pain relief was often sufficient (> 95%), but females more often had moderate to severe pain on arrival in hospital ( n =34; 5.0% vs.  n =59; 3.2%;  p =0.043). Administration of potent analgesics was safe, as indicated by MEES, SpO 2  and respiratory rates. On 10% of all missions, clinical patient assessment was deemed sufficient by HEMS physicians and monitoring was spared.    Conclusions  Opioids and esketamine alone or in combination were the analgesics of choice in physician-staffed HEMS in Austria. Analgesia was often sufficient, but females more than males suffered from oligoanalgesia on hospital arrival. Administration safety was high, justifying liberal use of potent analgesics in physician-staffed HEMS.    Supplementary Information  The online version contains supplementary material available at 10.1186/s13049-021-00839-9.

Analgesia in adult trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis