Pain Control

[MrBrown]

The chair of our Clinical Management Group is both a consultant anaesthetist and a consultant intensivest. Brown has two uncles who are consultant anaesthetists and a very good friend who is a HEMS Doctor (anaesthetist) and Browns side interest is anaesthesia. It is therefore fair to say we have one or two analgesia options in our bag of tricks and that Brown is not afraid to use them ...

We have methoxyflurane, morphine on its own, morphine+midazolam and ketamine. Some areas have entonox still but Brown hears its being withdrawn.

Methoxyflurane is good for basic stuff, busted arm, nungered shoulder, kidney stones etc while you get a bit of history and a drip going if narcotics are needed. It's also a good tool for our volunteer Technicians.

Morphine is good stuff, we have unlimited morphine here so it's up to the Ambulance Officer to decide how much the patient should get.

One thing nobody in the US seems to understand is that you can give different amounts of morphine to different people for different presentations. Everything Brown has seen generally says 2-4mg (both standing order and in educational material). Somebody who is screaming in pain from an angulated open femur is not going to be touched by 2mg of morphine and needs you know, a decent dose.

Examples of loading doses of morphine given here:

- Motorcyclist hit by a car who is agitated with several fractured ribs: 2.5mg
- Guy who fell out of tree with an open humerus fracture: 5mg
- Lady with kidney stones who had never had morphine before: 2mg
- Young bloke with bilateral coles fractures: 10mg
- Teenager who fell off fence and screaming in pain: 5mg
- Sick infarct with crushing chest pain: 1mg

We usually start off with a dose of between 2mg and 10mg depending upon presentation and cardiovascular state then go up in 2.5mg or 5mg increments, if pain is not sufficiently controlled by the time we've given somebody over 10-15mg its time to ring up Intensive Care for some ketamine. Repeat dosing of morphine is inappropriate if it is not relieving pain and its time to try something different.

Morphine+midazolam was introduced in 2001 here and works bloody wonderfully but it's largely fallen out of fashion now that we have ketamine. Example Brown has seen is some bloke with two femurs absolutely shattered to bits trapped in a car wreck, zonked him out nicely with some midaz and off to hospital he went.

Ketamine has been around since 2007 and it is the best thing Brown has ever seen, its just the most awesome thing since sliced bread.

If you do not adequately control your patients pain you are a clinically inferior provider who should not be allowed to touch patients.

 

[8jimi8]

Guess what? If you don't care about even attempting to help most of your patients pain, you are not a good provider, you never will be, and anyone who says you are is sadly mistaken.



The Paramedic who relieves me constantly calls me out for my aggressiveness of pain control (ex- 250mcg Fent and some Ativan for a tib/fib last week) and boasts that she has given pain control MAYBE 3 times in the past year, and that I have the "New medic med push syndrome" where I just want to push a med (though she's never been on a call with me). Maybe she's just angry that she has to go to the pharmacy to refill the narcs...



Just can't get through to some people. We have aggressive pain control guidelines for a reason...

Not questioning your judgement just curious. Because that dose seems pretty huge to me. (Granted when i have people on fentanyl, its a continuous infusion.)

was there any change in level of consciousness with that amount of fentanyl?

 

[usalsfyre]

I told you earlier how I was h34r: like today... your evil habits are rubbing off on an impressionable newbie!

(Imperial music in the background, best Darth Vader voice)

Feel the power of the Dark Side...soon you too will be asking for ketamine in our formulary....

 

[Shishkabob]

Not questioning your judgement just curious. Because that dose seems pretty huge to me. (Granted when i have people on fentanyl, its a continuous infusion.)

was there any change in level of consciousness with that amount of fentanyl?

I had him for over an hour from first contact to transfer of care. The 250 of Fent was throughout the whole time I was with him, and the final 50 was within 5 minutes of pulling in to the hospital.

Even with the 0.5mg of Ativan, there was no change in consciousness, just the usual "deep thinking mode" that patients go in to when they get Benzoes. Not as bad as a big dose of Ketamine, he was fully awake and conversing, but he took a bit longer to respond to questions.

Feel the power of the Dark Side...soon you too will be asking for ketamine in our formulary....

You and I need to get in talks about getting Nitronox... I think that should fix some of the apprehension that some medics have.

 

[Aidey]

Not questioning your judgement just curious. Because that dose seems pretty huge to me. (Granted when i have people on fentanyl, its a continuous infusion.)

was there any change in level of consciousness with that amount of fentanyl?

I've given doses like that a couple of times, generally in long transports. I gave one pt 275mcg. 300lbs, dislocated shoulder, 3-4 broken ribs, hour and 20 min transport down hill for the first 1/2. Aside from being more relaxed and calm there was no significant change in LOC.

 

[Aidey]

You and I need to get in talks about getting Nitronox... I think that should fix some of the apprehension that some medics have.

I used to have it, and I loved it. It was awesome, and has few contraindications. No needles, self dosed, no over sedation, good pain relief, need I go on?

The biggest thing I have heard against it are control issues. I think that could easily be remedied with a regulator that has a counter on it that counts each discharge.

 

[Shishkabob]

I had Nitronox at the agency I did my Paramedic school internship at and LOVED it for all the reasons you mentioned.


Just, from what I've been told, it's not extensively used because of the high costs associated with it since the FDA wont allow a pre-mixed version, and you need the Nitrogen bottle and the O2 bottle.

 

[Aidey]

We had an adapter that plugged into the O2 port on the wall. Same as our Whisperflow CPAP units have now.

 

[8jimi8]

I had him for over an hour from first contact to transfer of care. The 250 of Fent was throughout the whole time I was with him, and the final 50 was within 5 minutes of pulling in to the hospital.

Even with the 0.5mg of Ativan, there was no change in consciousness, just the usual "deep thinking mode" that patients go in to when they get Benzoes. Not as bad as a big dose of Ketamine, he was fully awake and conversing, but he took a bit longer to respond to questions.




You and I need to get in talks about getting Nitronox... I think that should fix some of the apprehension that some medics have.

Oh. when I first read it, I read it as a 250mcg bolus. If you were dosing out aliquots, there doesn't even need to be discussion. The only other question is why didn't you use dilaudid? Do y'all have hydromorphone?

Aidey,

I am fully on board /c 1mcg/kg/hr. Often when I'm on the unit and see patients /c 8-10 mg/hr of versed on like ... 25mcg of fent.... i immediately change it to 1mcg/kg/hr of fentanyl and let that versed work its way out. It usually works out to a sweet spot of 75-90% of fentanyl /kg/hr and 1 - 2 mg/hr of versed.

I just don't understand why people set our patients up on such bad sedation packages.

We had a guy on 10mg of versed /s analgesia! I talked to the intensivist and asked him why the patient wasn't on fentanyl and he said... "NO ONE STARTED FENTANYL!!??!!"

 

[Shishkabob]

No hydromorphone... Fentanyl is our only opiod. We then have Ativan and Versed as our Benzos.


Our Fentanyl dosages used to be 1-2mcg/kg with no true limit (3mcg/kg for RSI). However, apparently some medics walked in to ERs multiple times with patients totally snowed on Fent, so now we're 1mcg/kg Fent, can be repeated another time for a total of 2mcg/kg Fent... for acute pain for patients between the ages of 10-70. Everything else they'd prefer if we called.

 

[8jimi8]

At least you've got 1mcg/kg. That is a healthy dose that should cut anything in half.

Repeat dosing should handle the long transports. If you need more, you need versed!

Nice work Linuss, I'm proud of you.

Just remember... As Bob Marley said... "who feels it, knows it"

 

[usalsfyre]

At least you've got 1mcg/kg. That is a healthy dose that should cut anything in half.

Repeat dosing should handle the long transports. If you need more, you need versed!

Nice work Linuss, I'm proud of you.

Just remember... As Bob Marley said... "who feels it, knows it"

The problem before was we had too many medics who thought 2mcgs/kg was a good starting point for a fast push. On 4ft9 100kg patients.

To give you an idea of most of these medics inexperience with opioids, our previous morphine dose was 0.04mg/kg...

 

[Icenine]

The protocols for medics here don't allow for versed. They have been finalizing a rewrite of our protocols for about the last 2 years and I'm told they allow for much better pain control. Until a few years ago the only ALS agencies in the county shared a zip code with both of our hospitals. Now there are more than a few with 40+ min transport times.

Morphine 2-5 mg every 5 min (unlimited)

If allergic or unresponsive to Morphine, 50 mcg Fentanyl w/ 1 additional 50 mcg dose in 5 mins.

Tordol 30 mg 1 time

4mg Zofran 1 time

 

[the_negro_puppy]

At my level we have only methoxyflurane (inhlaer), paracetamol and morphine.


Makes it interesting when you have a pt thats in moderate pain, has had paracetamol within 4 hours, cant have methoxyflurane (hx liver cancer with recent jaundice/bilary stent) and is hypotensive +tachy (? sepsis).

Our protocols state that hypotension = 2.5mg increments and Intensive Care Paramedic backup must be requested if giving. When you are 15 minutes from hospital, and waiting for ICP backup will probably take 10-15 mins (road speed) its frustrating when you have to leave the pt in pain til they get to hospital.

It would be good to have another option, with Ketamine only an ICP drug for bad fracture pain management

 

[medicRob]

Nothing pisses me off more than the providers who play the "Who is a drug seeker" game. In the patient bill of rights, one of their rights is the right to not be in pain.

Also, as a wise medic said:

2 mg of morphine + Severe Pain = Severe Pain.

 

[MrBrown]

Also, as a wise medic said:

2 mg of morphine + Severe Pain = Severe Pain.

Anybody who gives 2.5mg of morf so somebody in severe pain should be relegated to driving

Our protocols state that hypotension = 2.5mg increments and Intensive Care Paramedic backup must be requested if giving. When you are 15 minutes from hospital, and waiting for ICP backup will probably take 10-15 mins (road speed) its frustrating when you have to leave the pt in pain til they get to hospital.

It would be good to have another option, with Ketamine only an ICP drug for bad fracture pain management

Do you have a copy of the QAS procedures somewhere?

Paramedic here (~QAS ACP) have methoxyflurane, paracetamol and morphine too. We can give 1.5g to somebody who has had paracetamol four hours ago and don't have to ring up for Intensive Care if we are giving morph to somebody who is hypotensive.

Brown would be judicious about morphine in hypotension, if you think they are septic they should be getting a litre of fluid anyway.

 

[the_negro_puppy]

Anybody who gives 2.5mg of morf so somebody in severe pain should be relegated to driving



Do you have a copy of the QAS procedures somewhere?

Paramedic here (~QAS ACP) have methoxyflurane, paracetamol and morphine too. We can give 1.5g to somebody who has had paracetamol four hours ago and don't have to ring up for Intensive Care if we are giving morph to somebody who is hypotensive.

Brown would be judicious about morphine in hypotension, if you think they are septic they should be getting a litre of fluid anyway.

The first thing I did once loaded was run a bag of fluids (got about 500ml before arrival)


Also the 2.5mg increment is for hypotension with systolic BP < 90 mmhg. This patient was 75/48 o/a mainting in different positions. 500ml of fluid = 82/53 roughly o/a hospital.

Ive attached a copy of QAS DTPs for your perusal

 

[cruiseforever]

One thing nobody in the US seems to understand is that you can give different amounts of morphine to different people for different presentations.


How can one make that statement? When I first started in EMS it was a big deal to give 5-10 mg of Morphine Sulfate. But now we have grown and earned the trust and respect of our Medical Control. Some areas in the US are very progressive in dealing with pain control. I wish people would stop coloring everything with one stroke of the brush.

 

[18G]

Pain management is something I take seriously as a Paramedic and feel like my system has pretty decent standing orders for pain management with both morphine and Fentanyl available. We can also use nitrous oxide but I don't know of any EMS Department that carries it.

We just had our pain management protocol revamped and now have standing orders for pain management in patients with acute onset back pain and acute thoracic / rib pain after trauma. Before it was just for suspected isolated extremity fractures unless of course we consulted for orders.

Here is a link that gives some good perspective on attitudes surrounding pain management in EMS and Emergency Medicine and why there is still hesitation to treat pain aggressively.

http://www.emsworld.com/print/EMS-World/Taking-EMS-Into-Tomorrow--Part-6/1$4214

 

[MrBrown]

How can one make that statement? When I first started in EMS it was a big deal to give 5-10 mg of Morphine Sulfate. But now we have grown and earned the trust and respect of our Medical Control. Some areas in the US are very progressive in dealing with pain control. I wish people would stop coloring everything with one stroke of the brush.

Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?

Brown has seen one area (Wake County) has entonox and it's a Paramedic (ALS) level skill for frig sake, back in 1975 our one week trained Elementary Ambulance Aid Officers could give entonox.