Pain Management + unresponsive patient
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I'm assuming that you mean a patient that is completely unresponsive and you're wondering if there's any sort of preemptive pain management protocol to cover the pain that will be felt when they regain consciousness... and beginning said pain management while in the field?
Given that many times we're either not allowed to medicate for pain, or we're limited to (usually) isolated extremity Fx, I doubt that such a protocol exists in any widespread manner in the US. Prehospital pain management in the US is horrible, generally speaking, and has been for quite a long time.
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Patients that are unresponsive due to trauma have some bigger issues to fry than managing pain. If the altered mentation is caused by hypoperfusion of the brain secondary to hypervolemia, most pain management protocols don't want you dumping opioids on top of that hypotension. If it's a direct insult to the head causing swelling and an increased ICP, a brain that is not allowing consciousness probably isn't allowing pain to get through to any conscious center of the brain either. In injuries this bad, pain management comes after the patient is stabilized and conscious enough to recognize or remember pain.
DrankTheKoolaid
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The only time it is in protocols here in my secondary LEMSA is post intubation during transfer. And that would for both continued sedation and analgesia to allow ETT/vent tolerance. Taking into consideration whatever pathophysiological insult the patient has received
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Then you throw in what chaz posted as to why we don't do pain management in patients this bad... there's little actual reason (in the immediate sense) to begin doing pain management in the field for them. Besides, as chaz said, patients that are so bad off that they're unconscious/unresponsive after a traumatic incident probably have bigger problems going on that have to be managed first.
I see, thanks for the responses.
With what Chaz is saying, would pain management be withheld if the trauma patient, was responsive/unresponsive throughout the transport. Awake and screaming-out cold, awake and screaming....
NomadicMedic
I know a guy who knows a guy.
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If he could talk to me and was screaming from the pain, he would get medicated.
If he was unresponsive and busted up, he'd probably wind up getting RSI, and yes, he'd then get (some) pain management.
If he was unresponsive and busted up, he'd probably wind up getting RSI, and yes, he'd then get (some) pain management.
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This
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And if you can't do RSI or any other form of facilitated intubation, you medicate while the patient is awake and screaming. Unfortunately, occasionally you won't be able to medicate because the patient's injuries don't match what your protocols authorize (or the amount won't touch the pain anyway) or your OLMC won't give you orders for it...:sad:
Melclin
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This.
I'll add that if the patient obvious pain producing injuries is not completely unconscious but too combative to manage, opiates rather than benzos are the go. Opiates until they shut up, and let you treat them, then.. generally...RSI.
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We can medicate altered patients after a traumatic injury, just have to be cautious doing it.
Like everyone else said there are bigger things to worry about if they're completely unresponsive and they'll get some when they get RSId
Like everyone else said there are bigger things to worry about if they're completely unresponsive and they'll get some when they get RSId
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Although it is not in many protocols, analgesics should indeed be used in conjunction with paralytics and sedatives (unless you're sedating with something like Ketamine, which also has analgesic properties).
Not horrible (very commonly done in the ED even) but you should really be following it up with opiates and benzos (unless your using ketamine or propofol for continued sedation) post-intubation. The procedure hurts, the tube in their glottis hurts, the two in combination work much better than benzos alone.
That said, it's much better than the 5mg of versed and brutane...
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NomadicMedic
I know a guy who knows a guy.
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The RSI/pain management thread has been moved here: http://www.emtlife.com/showthread.php?t=35931
jefftherealmccoy
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Why do you say opiates rather than benzos?
Our protocols deny us use of opiates if pt has head trauma (all we got is morphine, unfortunatly). What i've seen is if the pt is combative, it's normally because they've cracked their head pretty good on something. I've also seen a pt become combative as he bled out (feeling of impending doom). Both cases we've used Valium.
we use the same, but after we get the tube we follow it up with Valium and Rocuronium.
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I'm going to make an educated guess why opiates instead of benzos... Opiates can have sedative effects and produces some level of analgesia where benzos have sedative effects but don't have analgesic properties. In other words, benzos can sedate but "it" still hurts. Opiates can make "it" not hurt as much while possibly helping with sedation so the patient doesn't care that it hurts either...
Down side with either is that it can be possible to dump the patient's BP with administration of either.
That's probably the logic behind the statement. I could be completely wrong because I'm not Melclin, nor do I work in the same part of the world... (Standard disclaimer, you know.
)jefftherealmccoy
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I'm going to make an educated guess why opiates instead of benzos... Opiates can have sedative effects and produces some level of analgesia where benzos have sedative effects but don't have analgesic properties. In other words, benzos can sedate but "it" still hurts. Opiates can make "it" not hurt as much while possibly helping with sedation so the patient doesn't care that it hurts either...
Down side with either is that it can be possible to dump the patient's BP with administration of either.
That's probably the logic behind the statement. I could be completely wrong because I'm not Melclin, nor do I work in the same part of the world... (Standard disclaimer, you know.
here's my question for you (or anyone else for that matter)
What would you with a combative trauma pt with low-ish bp that is combative? Morphine or valium?