# What pain management options do you have?



## Aidey (Oct 9, 2010)

With the recent discussions on pain management I'm curious what options people have available to them to manage pain. So...

What meds do you carry?
What non-narcotics are available for pre hospital use?
Anyone using IV muscle relaxants that are not benzos?
Anyone using PO meds?
Do you have a protocol for conscious sedation?


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## 46Young (Oct 9, 2010)

Fent 0.5 mcg/kg for injuries and suspected kidney stones, 1 mcg/kg for Cx discomfort w/ cardiac etiology, both standing orders. 

Versed for cardioversion and pacing, 2 mg standing orders.

Zofran for N/V, 4 mg IVD mixed in 100 cc NS, 10 gtt set, wide open, or 4 mg P.O. S.O. Not pain management per se, but certainly a comfort measure.

O2, cold packs, and vacuum splints, which help greatly w/ immobilizing extremities and allowing us to move the pt w/ greatly reduced pain, or even no pain whatsoever.

No RSI. We have our medevacs and also Fairfax City txp crews that can do it if we request it. QA/QI issues and close proximity to area hospitals are the reason I'm given for no RSI at my dept.

Edit: Forgot, morphine for injuries, stones, and cardiacs, 1-10 mg, can call for more w/o any issue, usually.


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## MrBrown (Oct 10, 2010)

Methoxyflurane, paracetamol and unlimited entonox, morphine, midazolam and ketamine.

We have conscious sedation and RSI.

All are written Guidelines with no base hospital contact required, not that we have ever had that anyway!


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## Flight-LP (Oct 10, 2010)

Our options are:

Fentanyl 1-2mcg/kg prn for pain, up to 3mcg/kg for sedation or induction.

Ketamine 1.5mg/kg for pain, sedation, and induction.

Morphine 0.05-0.1mg/kg prn.

We have Ketorolac available for IM and IV use.

Vesed and/or Ativan for sedation, anxiety, or muscle relaxation.

Reglan, Zofran, and Phenergan for nausea / comfort.


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## MrBrown (Oct 10, 2010)

I'm guessing that you guys don't hire 12 week Parathinktheyare's and Medicfighters from the Paramedic patch factory for the barely homeostasasing if you use all those meds


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## the_negro_puppy (Oct 10, 2010)

Morphine IV/IM
Paracetamol
Methoxyflurane inhaler


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## Melclin (Oct 10, 2010)

Methoxyflurane
Inhalant. 2x3ml doses. Great for quick relief before cannulation or for procedural pain like a reduction or moving onto a stretcher, putting a splint on etc. 

Morphine IV/IM
Up to 20mg (anymore requires a consultation with a more experienced medic). No limit for Intensive Care paramedics.

Fentanyl IN 
200mcg first dose, 4 x 50mcg q5. Paeds: 2mcg/kg, 2 x 1mcg/kg q5 (IV at Intensive Care level, 25-50mcg boluses). 

Ketamine is being trialed at IC level in some places. Don't know much about it.

We have lignocaine, but its only there for combination with IM ceftriaxone when you can't get IV access. Needless to say, that doesn't happen too much. 

I wish we had an NSAID, an option for combining Midaz and morpine, and IV fent at the basic level. OTC PO meds are only an option if the person happens to have some at their house, not to many medics use that option, but some do.

We have conscious sedation at IC level but not for pain relief.


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## Flight-LP (Oct 10, 2010)

MrBrown said:


> I'm guessing that you guys don't hire 12 week Parathinktheyare's and Medicfighters from the Paramedic patch factory for the barely homeostasasing if you use all those meds



Nope, not a chance in he!!........

We do not even consider applicants with less than 3 years quality experience.


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## usalsfyre (Oct 10, 2010)

Fentanyl is our front line., 1-2mcg/kg q 10

If that's inadaquate, we can (after med control consult) combine it with midazolam/lorazepam 0.5-2mgs of either. Either of these can also be used as a stand alone for agitaion

I've carried nitronox at one service, and I miss it greatly. However, from what I understand they don't make the blenders anymore, and the FDA has a hissy fit over single bottle Entonox. 

Zofran is currently our only antiemetic, due to some wundermedics who didn't understand the concept of dilution.  

I'd love to see more pain management options like APAP, hydromorphone (for certain situatons) and Toradol. I am pretty satisfied with what we can do to sedate. Our antiemetic option sucks once they've actually puked, Reglan, or even including diphenhydramine (old school) for N/V refractory to Zofran would be nice. Overall though, our service has just recently started making pt comfort a concern, a year ago pain control was limited to 0.04mgs of morphine for extremity trauma or burns, nothing else. So we've improved vastly. I see this trend continuing, as our medics, patients and med control have all been very satisfied. Now if we could just get our outlying hospitals to understand why we do this.


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## dmiracco (Oct 10, 2010)

We have Ketamine, Fentanyl, Nitrous Oxide all great choices foer different situations 
Versed and Valium but would like to Ativan


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## TransportJockey (Oct 10, 2010)

I have to ask, what service in NM used Nitrous? Or Ketamine for that matter? I'm just curious, since I've never heard any of the flight medics I know for SW or TSCF say anythign about those.


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## firecoins (Oct 10, 2010)

We knock them out by hitting their head with a stone.


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## Melclin (Oct 10, 2010)

usalsfyre said:


> F Overall though, our service has just recently started making pt comfort a concern, a year ago pain control was limited to 0.04mgs of morphine for extremity trauma or burns, nothing else. So we've improved vastly. I see this trend continuing, as our medics, patients and med control have all been very satisfied. Now if we could just get our outlying hospitals to understand why we do this.



0.04mgs of Morphine...? Even for the US that has gotta be a typo 

What don't the hospitals understand?


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## usalsfyre (Oct 10, 2010)

Nope, no typo we used to give a 100 kilo patient 4mgs of morphine, one time. Kind of the equivilent of putting a bandaid on a severed limb...

There are two large services in our area. One affiliated with one major health system, the other with the two other major health systems (the one I work for). As I said, service two recently did a major protocol overhaul, and pain managment is high on that list. What went along with this has been about 75 hours of additional CE spread out over the year, helping to bring all of our medics (even the low performers) up to a minimum level of practice.

Service one on the other hand, practices next to no pain management. The only option available to them is 2mgs of nalbuphine, given only for "extreme" pain (their words not mine). There's also a smattering of smaller services that practice typical 1990s EMS pain management.

The result of all this is the doc in the boxes dislike prehospital pain management, for all of the tired old reasons. The local hospital that I transport to pretty much balls me out everytime they I bring them a patient with meds on board. Which has resulted on me, my supervisor, and my clinical and medical director placing them on the ignore list. There's still a lot of education about  EMS best practices to be done among the crowd that hangs around little rural EDs.


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## NomadicMedic (Oct 10, 2010)

Morphine: 2-4mg up to 20mg without calling.
Fentanyl: 25mcg, up to 200 mcg without calling.
Ketorolac: 50mg for kidney stones.

We also carry Valium, Versed and Ativan for sedation and/or anxiety, as well as Droperidiol, Phenergan, Zofran and Diphenhydramine, which we may use as an antiemetic or sedation as we see fit.


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## LonghornMedic (Oct 10, 2010)

Fentanyl 1 mcg/kg IV/IM/IN. May repeat 0.5 mcg/kg every 5 minutes to a max of 300 mcg.

Tylenol.

Ibuprofen. However its only indication is for fever.

Midazolam to piggyback an analgesic if needed.

Diazepam to piggyback an analgesic if needed.

I'm not a huge fan of fentanyl. Just doesn't get the pain control that morphine achieved. I miss when we could give morphine and phenergan. The combo of those two made for great pain control.


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## LonghornMedic (Oct 10, 2010)

n7lxi said:


> Morphine: 2-4mg up to 20mg without calling.
> Fentanyl: 25mcg, up to 200 mcg without calling.
> Ketorolac: 50mg for kidney stones.
> 
> We also carry Valium, Versed and Ativan for sedation and/or anxiety, as well as Droperidiol, Phenergan, Zofran and Diphenhydramine, which we may use as an antiemetic or sedation as we see fit.



Toradol for kidney stones? I've had over 20 in my life and just about every time some ER doc tries to use that garbage. Doesn't work for me. Do they allow you to administer MS of fentanyl in adition to toradol?


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## jjesusfreak01 (Oct 10, 2010)

Fentanyl, Toradol, Lidocaine, Versed, Morphine, and Haldol. Dilaudid is approved but I do not believe we carry it.


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## NomadicMedic (Oct 10, 2010)

LonghornMedic said:


> Toradol for kidney stones? I've had over 20 in my life and just about every time some ER doc tries to use that garbage. Doesn't work for me. Do they allow you to administer MS of fentanyl in adition to toradol?



Luckily, our docs believe in pain management and and trust the medics. So, if I had a case with a patient that presented with kidney stones and a history of the same and told me that Toradol hadn't touched his pain in the past, I'd have no problems getting orders for MS or Fentanyl. We have long transport times, upwards of 40 minutes, so I'll do what I can to make the patient comfortable. 

As an aside, I've also had kidney stones (it sucked) and the combo of Ativan and Toradol worked for me.


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## TransportJockey (Oct 10, 2010)

Toradol works wonders for biliary pain as well, from past experience


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## Outbac1 (Oct 10, 2010)

For pain:   Morpine  up to 15mg, maybe more if we call and ask nicely.
 For sedation: Versed up to 10mg.

 We also have Diazepam (Valium) for seizures and Diphenhydranate (Gravol) for N&V.  I wish we had Fentynal and Toradol as well. Not everyone can have morphine and it doesn't always work.


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## dmiracco (Oct 11, 2010)

Paintball,

I no longer work in NM, Im in TX but thanks for noticing. I just havent changed my profile thingy. :blink:


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## Flight-LP (Oct 11, 2010)

jtpaintball70 said:


> I have to ask, what service in NM used Nitrous? Or Ketamine for that matter? I'm just curious, since I've never heard any of the flight medics I know for SW or TSCF say anythign about those.



Native Air (formerly known as SWME / Omniflight) carries Ketamine. It was added last year when the CPG's were revised.


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## TransportJockey (Oct 11, 2010)

Flight-LP said:


> Native Air (formerly known as SWME / Omniflight) carries Ketamine. It was added last year when the CPG's were revised.


Cool thanks  its been a while since I dealt with flight teams on a regular basis. I used to see fixed wing PHI and SWME crews on a very regular basis since I ran the BLS night truck at my old service.


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## TransportJockey (Oct 11, 2010)

dmiracco said:


> Paintball,
> 
> I no longer work in NM, Im in TX but thanks for noticing. I just havent changed my profile thingy. :blink:



No problem  I usually smile when I see other NM providers on here since they don't tend to hang around. Although I'm another NM EMT that's most likely going to TX, so I shouldn't say anything


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## dmiracco (Oct 11, 2010)

Lol the only way a NM 911 service could obtaion those medications would be for that service to do a special skill application through the state and thats ALOT of work. I have done that for AMR in Dona Ana county for cardizem.


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## johnrsemt (Oct 12, 2010)

Fentanyl
Morphine
Demerol
Versed


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## medic417 (Oct 12, 2010)

My drug bags bigger than all of yours combined. :lol:


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## jjesusfreak01 (Oct 12, 2010)

medic417 said:


> My drug bags bigger than all of yours combined. :lol:



I bought a Pyxis for my truck.


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## 46Young (Oct 12, 2010)

jjesusfreak01 said:


> I bought a Pyxis for my truck.



I bought some shares in a broad pharmaceutical fund. I technically own a piece of everything, including al the meds in your pyxis.


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## Melbourne MICA (Oct 12, 2010)

*Options*

Analgesia//

Morphine  IV/IM PRN (no specific limit)
Fentanyl  IN/IV 200mcg IN 1st dose 25-50mcg increments IV
Ketamine IV (severe orthpaedic pain only eg long bone fractures)
Methoxyflourane inhaled 2 x3ml doses max

Sedation//

Midazolam and Fentanyl (inductions)
Midazolam and Morphine (sedation infusion post inductions/intubations)
Midazolam (agitated pt)

MM


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## BLSBoy (Oct 12, 2010)

Career Fire/Transport in Fla;
Fent, 100mcg loading dose, 50mcg q5 min up to 250mcg
Morphine, 2mg, q5 min up to 10mg
Nitrous is pt administered. 

All meds can be upped with contact with medical control. 

Career EMS/MICU in South Jersey;
Fent; whatever the doc says. 
Morphine; whatever the doc says. 

Some docs were aggressive. Some hated us. And God help you if you can't make contact with medical control and need to give pain meds or any other controlled substances. If you survive the initial ZOMG YOU GAVE MEDS WITHOUT PERMISSION?!?!, the paperwork you are buried in will take a tour to complete. 

I like Fla. :wub:


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## TraprMike (Oct 13, 2010)

firecoins said:


> We knock them out by hitting their head with a stone.




TRUE STORY: several years ago, my oldest son had a very bad tooth ache. he was like 10 at the time.  it was just before closing time at the dentist office. the Dr. told me to give him a shot of whiskey every couple hours and come in, in the morning.... 

wish i would of recorded that convo...


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## usalsfyre (Oct 13, 2010)

Melbourne MICA said:


> Analgesia//
> Fentanyl  IN/IV 200mcg IN 1st dose 25-50mcg increments IV



Question, because I've been playing with IN Fentanyl quite a bit here lately and the AUS and NZ providers seem to be the experts on it. 

Does the higher inital dose provide supperior relief via the IN route? Our guidelines call for the same dose (1-2mcg/kg) no matter the route, so I've usually been going with 75% or so of the first dose IN with the remainder of the 1st dose IV once I can get them in position which an IV start is convinent for everyone. Should I be hitting them with higher doses right off the bat?


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## Emtpbill (Oct 13, 2010)

n7lxi said:


> Morphine: 2-4mg up to 20mg without calling.
> Fentanyl: 25mcg, up to 200 mcg without calling.
> Ketorolac: 50mg for kidney stones.
> 
> We also carry Valium, Versed and Ativan for sedation and/or anxiety, as well as Droperidiol, Phenergan, Zofran and Diphenhydramine, which we may use as an antiemetic or sedation as we see fit.



Droperidol ?   We used to carry that but I thought it wasn't approved for prehospital use anymore because of prolonging Q-T.


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## Flight-LP (Oct 13, 2010)

Emtpbill said:


> Droperidol ?   We used to carry that but I thought it wasn't approved for prehospital use anymore because of prolonging Q-T.



While there was a FDA black box warning, Droperidol is still quite popular. There is a concern about Q-T prolongation, but many (myself included) believe the initial concerns were dramatically overexaggerated.


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## Melclin (Oct 14, 2010)

usalsfyre said:


> Question, because I've been playing with IN Fentanyl quite a bit here lately and the AUS and NZ providers seem to be the experts on it.
> 
> Does the higher inital dose provide supperior relief via the IN route? Our guidelines call for the same dose (1-2mcg/kg) no matter the route, so I've usually been going with 75% or so of the first dose IN with the remainder of the 1st dose IV once I can get them in position which an IV start is convinent for everyone. Should I be hitting them with higher doses right off the bat?



The higher dose as I understand it is due to limited absorption. IN isn't equivalent to IV, which makes sense I spose. One of its bigger advantages is added pain relief for kids whom we cannot cannulate at the basic level here. 

For reference the complete guideline is:
Adult (>14yrs): (>60kg AND age <60yrs); 200mcg, 4x 50mcg q5. (<60kg and/or age >60yrs); 100mcg, 2x 50mcg q5.
Paeds: 2mcg/kg, 2x 1mcg/kg q5. 

With consideration to active asthma, the possible deleterious affects of combining it with amiodarone for our MICA chaps, elderly patients, pts with renal or hepatic impairment, COPD and combination with MAOIs. 

The studies that validated IN fent used smaller doses (still above 2mcg/kg for adults) and it was regularly not enough. So I would say it would be better to consider bigger initial doses, within protocol and reason of course, etc. I feel our max doses are still on the conservative side for kids esp. But we shall see what I feel once I get out there using it regularly. It is encouraged that IN doses be followed up with prompt IV morphine with obvious consideration to combining the effects. MelbMICA will be far more useful to you in that regard. 

It seems to work better in some pts than others. Anecdotaly, I've seen it work faster and with more reliable analgesia in younger pts. It seems to be a bit unpredictable in older people. A few other people have agreed with that observation, but its just based on opinion as far as I know, so take it or leave it. I've got the references to just about all the IN fent research ever done, so shoot me a PM if you want the list.

Like IN naloxone, there's a bit of an issue with concentration. You've got to have a high concentration drug prep otherwise you end up squirting litres of fluid up their nose. For the IN route, we carry 900mcg/3ml vials. What presentation of fent are you using?


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## usalsfyre (Oct 14, 2010)

250mcg in 5ml is the sole concentration we carry. So that ends up with a 100mcg dose being 2ml, I usually split it 1ml a nare. I have found there is a certain amount of technique to getting maximum atimozation (and thereby absorption) with the MAD devices.

My general routine has been 75-100mcg IN, move the patient, start the line, then follow up with 50-75mcg IV. I haven't had a problem with oversedation yet, but find the IV dose is needed to maintain and/or achieve adaquate pain control. 

Andectolally, I'll agree with the assertion it works better in the young. I've seen much better absoption on these patients as well, a few of the elderly patients I've used it on have been unable to coordinate their breathing with the administration and have ended up with half the meds dripping out of their nose. I do wonder if it has something to don with mucosal changes as we get older.


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## firecoins (Oct 14, 2010)

TraprMike said:


> TRUE STORY: several years ago, my oldest son had a very bad tooth ache. he was like 10 at the time.  it was just before closing time at the dentist office. the Dr. told me to give him a shot of whiskey every couple hours and come in, in the morning....
> 
> wish i would of recorded that convo...



we can use scotch but not whiskey.


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## YoungMedic (Oct 17, 2010)

Morphine
Versed 
Ativan
Valium
Zofran

Consious sedation and RSI (Got to be 2yr medic for RSI)
Would like to see Fentanly in our box.


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## LonghornMedic (Oct 17, 2010)

YoungMedic said:


> Morphine
> Versed
> Ativan
> Valium
> ...



Fentanyl is overrated in my opinion. I wish we had it back.


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## LonghornMedic (Oct 17, 2010)

LonghornMedic said:


> Fentanyl is overrated in my opinion. I wish we had it back.



I should clarify...I wish we had morphine back.


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## emt_irl (Oct 18, 2010)

at basic level here we can give entanox and paracetamol soon to be updated with new 2011 education and training standards


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## MrBrown (Oct 18, 2010)

emt_irl said:


> at basic level here we can give entanox and paracetamol soon to be updated with new 2011 education and training standards



Updated to include what?


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## jjesusfreak01 (Oct 18, 2010)

MrBrown said:


> Updated to include what?



Chest tubes


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## emt_irl (Oct 19, 2010)

MrBrown said:


> Updated to include what?



the final decision is up in the air still, but apperently there to include ibprofen mainly because we deal with alot of soft tissue injuries


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## slb862 (Oct 20, 2010)

Fentanyl
Morphine
Versed
Ativan
Toradol
Lidocaine
Zofran
Nubain

Let's not forget the good ole O2.

I prefer Fentanyl anyday, along with bump of Morphine, then add a little Versed.  Yummy, and then don't forget the Zofran when the Morphine makes them wanna puke.


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## usalsfyre (Oct 22, 2010)

slb862 said:


> Let's not forget the good ole O2.



I'm fairly certain, that despite the lies told everyday in EMT classes nationwide, O2 has no analgesic properties...


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## reaper (Oct 22, 2010)

No, but O2 works in different ways, which can reduce pain. Headache treatments is one good example. High flow O2 is one of the best treatments available. So never under estimate the little power of O2! Haha


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## usalsfyre (Oct 22, 2010)

reaper said:


> No, but O2 works in different ways, which can reduce pain. Headache treatments is one good example. High flow O2 is one of the best treatments available. So never under estimate the little power of O2! Haha



O2 has been definitively shown to be effective for pain only in the setting of cluster headache, by an unknown mechanism. I've never come across anything else claiming analgesic properties besides a few misguided EMS instructors. So never overestimate O2 either h34r:.


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## reaper (Oct 22, 2010)

usalsfyre said:


> O2 has been definitively shown to be effective for pain only in the setting of cluster headache, by an unknown mechanism. I've never come across anything else claiming analgesic properties besides a few misguided EMS instructors. So never overestimate O2 either h34r:.



Point exactly! We cannot overestimate O2, because we do not fully understand the function it provides on the body

It's use has been well documented in Cluster headaches. They have no idea why it works, just know that it does. Until we completely understand how it works on different receptors, we cannot say that it has no analgesic effects!


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## usalsfyre (Oct 22, 2010)

reaper said:


> Point exactly! We cannot overestimate O2, because we do not fully understand the function it provides on the body
> 
> It's use has been well documented in Cluster headaches. They have no idea why it works, just know that it does. Until we completely understand how it works on different receptors, we cannot say that it has no analgesic effects!



Pain in general is not a well understood reaction. We have however, managed to isolate most of the neurons and receptor systems responsible for pain and analgesia. Thing is, oxygen reacts with none of them. The only receptors O2 (notice O2, there are oxide neurotransmitters) interacts with regularly are chemo and baroreceptors. So O2, by it's self, does not provide analgesia. O2 won't make a broken femur feel better, narcotics will. Cluster headaches are the proving exception.


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## swissmedic (Oct 24, 2010)

Hello everyone
I am 34 year old senior medic, I am working in hospital based system in SWITZERLAND.
We have no special pain management protocols,
We normally use morphine for any CHF patient, for any trauma patient we use fentanyle ( I really like this meds) or we use ketamine and dormicum (versed) and for pediatric we use nalbuphin, fentanyl or ketamine. So you have the choise, the right drug for every special situation...
We use iv, im, sc and io for any drug application

Matt


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## slb862 (Nov 3, 2010)

Let's not forget: Treat the patient.  I have used O2 as a calming "drug".  AND if the pt. finds it calming I find it easier to interact, enabling me to give  appropriate pain medications.  

Besides, if there was no O2 then we would all be screaming.  :blink:


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## usalsfyre (Nov 4, 2010)

slb862 said:


> Let's not forget: Treat the patient.  I have used O2 as a calming "drug".  AND if the pt. finds it calming I find it easier to interact, enabling me to give  appropriate pain medications.
> 
> Besides, if there was no O2 then we would all be screaming.  :blink:



Any evidence to back up use of O2 as an anxiolytic? Aren't there much more effective drugs for this purpose? How much have you learned about theraputic communication?


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## waltcallie (Nov 11, 2010)

MrBrown said:


> I'm guessing that you guys don't hire 12 week Parathinktheyare's and Medicfighters from the Paramedic patch factory for the barely homeostasasing if you use all those meds



Just remember "Mr. Brown", there is always someone faster, smarter, stronger, and better looking than you. Everyone was a newbie at one point or another and the ones who succeed are the ones who lose the attitude, remain humble, and let their skills do the talking. 
We're not out to take your job, you don't have to impress us! :beerchug:


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## 18G (Nov 11, 2010)

I think slb862 was referring to the psychological or placebo effect of giving someone a treatment (ie oxygen). The patient only think's that it is helping and in turn the patient calms themselves down. He wasn't insinuating oxygen has anxiolytic properties (least it didn't sound like it to me). 

However, this could be argued on a secondary basis. A hypoxic patient can be extremely anxious, you give them oxygen to correct the hypoxia, and in return they breathe better and have less anxiety hence an indirect anxiolytic property.


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## Mex EMT-I (Nov 12, 2010)

*pain management.....?*

Well, let me see.

If you are very brave you can give a pt ketorolac.
I say if you are brave, because when you arrive to the hospital the physician is gonna eat you alive.

And that´s it.

Few ambulance services in Mexico City carry and use strong analgesics. No morphine for the mexican people because it is a very VERY controlled drug. 

I envy you (and my patients who scream at every pothole we hit in the street also do).


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## Melbourne MICA (Nov 12, 2010)

*Collateral Damage*



Mex EMT-I said:


> Well, let me see.
> 
> If you are very brave you can give a pt ketorolac.
> I say if you are brave, because when you arrive to the hospital the physician is gonna eat you alive.
> ...



A truly unique and unenviable situation. Yet another example of the widespread effects on the community (yours in this case) of the activities of the drug cartels.
Mexican Paramedics are to be admired for their courage and sense of community. There are at least some people left in the world who have a moral imperative about public service and the good of all.

Money, money, money.

Capitalism sucks big time as far as I'm concerned. There's no future for societies vested entirely in self interest alone. There's no better example than the drug trade for both capitalism at work and the notion of pre-eminent self interest.

MM


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## Fox800 (Nov 15, 2010)

Our only medication option is IV/IN/IM fentanyl. Morphine was taken away about 2 years ago. Midazolam and diazepam were under a "pain/anxiety" management guideline but with our latest clinical guideline revision they are no longer approved for that use (which is unfortunate).


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## MrBrown (Nov 16, 2010)

Fox800 said:


> Our only medication option is IV/IN/IM fentanyl. Morphine was taken away about 2 years ago. Midazolam and diazepam were under a "pain/anxiety" management guideline but with our latest clinical guideline revision they are no longer approved for that use (which is unfortunate).



Why was midaz taken out? 

Brown is not really a fan of the "midaz people into orbit" trick because midaz is not an analgesic and just because the patient may not remember does not mean they are not still in pain.  Physical sensation of pain and physiologic response to pain are two different things and both need to be considered.

Thats why Brown likes having ketamine avaliable


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## Fox800 (Nov 16, 2010)

MrBrown said:


> Why was midaz taken out?
> 
> Brown is not really a fan of the "midaz people into orbit" trick because midaz is not an analgesic and just because the patient may not remember does not mean they are not still in pain.  Physical sensation of pain and physiologic response to pain are two different things and both need to be considered.
> 
> Thats why Brown likes having ketamine avaliable



I'm assuming it was removed because some providers were going overboard with the opiates + benzos combo. 

Straight from the horse's mouth:

"Anxiolysis in the setting of pain is resolved by removing the pain. Catacholamine stimulation and the subsequent anxiety is a normal physiologic response to pain. Treating the pain is treating the source rather than the symptom. The combination of narcotic pain relief and a sedative agent is conscious(procedural)sedation. This greatly increases the likelihood of respiratory suppression."


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## Aidey (Nov 16, 2010)

I don't give Versed for anxiety/sedation. It is used as a skeletal muscle relaxant in certain dislocations and fractures. It is a very fine distinction, but one our doc recgonizes, especially if you dose appropriately. It is amazing how much help just .5 of versed can do.


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## Melclin (Nov 16, 2010)

Aidey said:


> I don't give Versed for anxiety/sedation. It is used as a skeletal muscle relaxant in certain dislocations and fractures. It is a very fine distinction, but one our doc recgonizes, especially if you dose appropriately. It is amazing how much help just .5 of versed can do.



I've heard a bit about this idea and I'm quite interested to hear more. 

We can drive truck loads of midaz into an uncooperative pt but I get the feeling we'd get hauled over the coals if we went near a fracture or dislocation. 

Is midaz in any of your guidelines for this purpose?


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## Fox800 (Nov 17, 2010)

Melclin said:


> I've heard a bit about this idea and I'm quite interested to hear more.
> 
> We can drive truck loads of midaz into an uncooperative pt but I get the feeling we'd get hauled over the coals if we went near a fracture or dislocation.
> 
> Is midaz in any of your guidelines for this purpose?



We had kind of a blurred line. Diazepam was approved for muscle spasms/anxiety, but midazolam was also approved for anxiety.
It was part of a catch-all "pain/anxiety management guideline" that had fentanyl, diazepam, and midazolam as options. 

Our "violent patient guideline" featured midazolam exclusively.


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## socalmedic (Nov 17, 2010)

we have versed for anxiety/agitated Pt

agitation/combative: 1mg IV Q 2min PRN up to 5mg, or 0.1mg IM max of 5mg.

anxiety: 2mg IV repeate 1mg every 2 min PRN up to 5mg

pain: morphine 10mg prior to contact


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