Paramedic student pain management question

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David gold

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Hey guys!

I'm a paramedic student In Maryland. Our class is about a month away from the end of class and we now have final projects to complete. My topic was pain management in EMS. I thought it would be a good idea to get a survey from a bunch of different departments and see what you guys think. I would really appreciate it if you would include your general area, your current pain managemnt protocol, how effective you think it is and how you would like to see it change!

Thanks in advance for all the responses

David Gold
 
Southern CA. Pain management for us is pretty bad. Traumatic injuries/burns/chest pain is 5mg morphine (can repeat dose once) or 50mcg fent (may repeat once). my company is only catrying Fent. Any more and me must contact base. To give pain meds for any other reason than listed above is base order.

I hate our protocol right now. I wish we were able to titrate the pain meds. I wish we were able to give more than 10mg or 100mcg before base contact. I wish we would catch up to other areas who are currently giving pain meds to much more than just traumatic and ACS issues. I wish we also had other options for pain management aside from a narcotic.
 
My pain protocol - Chesterfield, VA
Consider Nitronox - however this is going away from us, being phased out.
Fentanyl 1mcg/kg IV, IN, or IM (max single dose of 50mcg)
--Sickle Cell patients may be given up to 100mcg.
If Fentanyl unavailable, give Morphine 0.1mg/kg IV OR IM (max single dose of 5.0mg)
-- Sickle Cell patients up to 10mg.
Consider Zofran 0.1mg/kg IV up to 4mg, in high risk patients.
After repeat pain assessment, if indicated, repeat med dose after 10min.
--Max Fentanyl - 200mcg (sickle cell - 400mcg)
--Max Morphine - 20mg (sickle cell - 40mg)
Consider Midazolam if pain persists, 0.05mg/kg (max single dose 2.5mg)
--If Midazolam unavailable, give Diazepam 0.125mg/kg up to 2.5mg.

Best of Luck.
 
Alberta Canada

0.1 mg/kg up to 5mg q5 to a max of 20 (morphine)

1mcg/kg up to 100mcg q3 to a max of 250 (fentanyl)

30mg Toradol

0.2mg/kg Ketamine
 
I'll summarize

For cardiovert and pacing 2-5mg morphine 25-50mcg of fentanyl
2mg increments to max to 20mg for cp
Trauma is 2-5mg max of 20mg
Anything more needs base orders

Peds is 4 doses or .1mg/kg max of 5 total max 20mg but whichever is less all of morphine
Our max fentanyl dose is 200mcg but we don't carry it.
I wish we did, but morphine tends to work fine unless their allergic and we can't give it
 
Victoria, Australia

Adult
Non-IV options:

>60Kg and <60Yrs: Fentanyl 200mcg IN repeat up to 50mcg IN @ 5/60 titrated to pain or side effects (MAX 400mcg)
<60Kg and/or >60Kg (or frail) Fentanyl 100mcg IN repeat up to 50mcg IN @ 5/60 titrated to pain or side effects (MAX 200mcg)

Methoxyflurane 3ml repeat to max of 6ml if required.

>60Kg Morphine 10mg IM - repeat 5mg IM after 15/60 (once only)
<60Kg Morphine 0.1mg/Kg (single dose only)

IV options

Morphine up to 5mg IV. Repeat up to 5mg IV @ 5/60 (Max 20mg) titrated to pain or side effects.
Fentanyl 25-50mcg IV. Repeat 25-50mcg IV @ 5/60 (Max 200mcg) titrated to pain o side effects.

Above are the ALS protocols. Intensive care paramedics have no maximum limit on the IV drugs. If further analgesia is required you can consult for more. Likewise if you need to step outside the above guidelines for clinical reasons and these can be clinically justified you can (consult is preferable).

There is a separate pain relief guideline for severe headache and paediatric patients. Also Midaz sedation for cardioversion .
 
Colorado.

Fentanyl 1-3mcg/kg, no max dose.
Morphine2-4mg q5min up to .2mg/kg.

If initial treatment has no effect:

Ketamine 0.3mg/kg no max dose (0.5mg/kg for IM and IN routes)

If Ketamine cannot be used can use 1-2mg of diazepam or midazolam along with fentanyl or morphine.
 
I still think the protocols are used in Yakima Washington where the best. RSI was on standing orders. Pain protocols included fentanyl or morphine, your choice up to 40 mg of morphine before calling for orders or 500 µg of fentanyl before calling for orders. It was unbelievably liberal.
 
Wow I can not thank you all enough for your responses!!!! Thank you!!!!
 
Delaware Statewide:

50-100 mcg Fentanyl IV/IM/IN, repeat dose 1x if needed. We carry a total of 400 mcg Fentanyl and can call for orders after a max of 200 mcg on standing orders.

For peds, we can give up to 2 mcg/kg up to a max of 50 mcg and repeat once if necessary prior to additional orders.

I would dearly love to have other options available besides Fentanyl (though if I had to choose one and one alone, Fentanyl would be it). I would also like the option to use Versed in conjunction on standing orders. I can call in for orders to use Versed with the Fentanyl and have done it on several occasions. I would also like the option to give up to 400 mcg on standing orders, particularly as we have some long transports, large people with hard working enzymes, and only short duration Fentanyl. I've had okay results calling in for additional orders. I find that when the doc is able to hear the patient screaming in pain over the radio after 200 mcg fentanyl it speeds the process along.
 
North Dakota
Pain protocol 0.5-1.5mcg/kg fentanyl max of 150mcg, may repeat in 10 minutes then after that it is repeated every 30 minutes
Along with fentanyl we can titrate up to 5mg of versed as needed.

If fentanyl and versed dont work we can switch to ketamine at .25mg/kg

No specific patients to provide pain management, if the provider wants to give it we are allowed to do so without calling.
 
1) There is no reason for anybody to be in acute pain anymore
2) Pain is bad, so see number 1

The general rule of thumb for us is

Mild pain - paracetamol and ibuprofen in combination,
Moderate pain - above plus oral tramadol and either entonox or methoxyflurane
Severe pain - as above plus morphine or fentanyl
Very severe pain - as above plus ketamine

There are also lignocaine ring blocks but I have never used one nor seen them used.

I really like what is available; lots of tools and it works very well.
 
Acute pain is the key pharse. We have been very aggressive in the treatment of pain. Maybe too aggressive. Here is a copy of medical directors wishes for pain control.

Background: The following addendum is based on increasing concerns regarding opioid and prescription drug abuse. While primary care and emergency departments are taking great strides to combat this problems, EMS utilization will likely increase as a means of obtaining these medications. In any patient with pain, the decision to use addictive medications should be done with caution, and unless there are obvious indicators of severe pain and/or injury, can wait until ED evaluation.
The following addendum applies to the 2014 Hennepin County EMS system ALS protocols:
PAIN MANAGEMENT – ADULT (pg. 25)
Additional contraindications:
· Headache
· Low Back pain (except as described below)
· Neck pain (except as described below)
· Any chronic pain (e.g. head, neck or back pain, fibromyalgia, abdominal or pelvic pain)
· Dental pain
Indications for use of Pain Management Protocol:
· Acute severe traumatic pain
o Neck or back pain from trauma and inability to ambulate from the incident
o Suspected broken bone. (severe tenderness to palpation WITH swelling and/or bruising)
o Severe traumatic chest or abdominal pain (ensure SBP > 90)
· Consider use for acute severe non-traumatic pain (e.g. Kidney stone) with 2 or more of the following factors which tend to predict need for prompt treatment
o Increased heart rate and/or blood pressure
o Nausea and/or vomiting
o Writhing
o Described as severe (or 8-10/10 on pain scale)
o Less than 2 hours duration
· Cardiac pain should only be treated with opioids if there are ischemic changes on ECG and not responding to nitroglycerine.


For patients experiencing pain outside the above listed indications, provide symptomatic relief of nausea/vomiting if needed. Advise them of the general concerns in the medical community about opioid use and that doctors are being very careful about which patients receive these addictive medications. Inform them that we carry this type of medication for severe trauma (e.g. broken bone) and for certain rare medical situations that require immediate pain control such as heart attacks. Reassure the patient that the receiving facility will be notified of the need for prompt pain management assessment.
 
Ontario, Canada

Advanced Care Paramedic Pain Medical Directive

Indications:
Severe Pain
AND
isolated hip or extremity fractures or dislocations OR major burns OR current Hx of cancer related pain OR renal colic with prior Hx OR patients with acute musculoskeletal back strain OR ongoing transcutaneous pacing

Conditions;
Fentanyl: >18 years, Unaltered LOA, Normotension
Morphine: >18 years, Unaltered LOA, Normotension

Tx;
Fentanyl: 25-50mcg IV, Max single dose: 50mcg Q5min, 4 doses.
Morphine: 2-5mg IV, Max single dose: 5mg Q5min, 4 doses.

Base hospital patch may be made for any patient outside of the protocol or if more pain control is needed. Midazolam may also be considered by a base hospital physician.

This is provincial standard, some base hospital groups have augmented this and are currently adding paediatric protocols as well.

Hope this helps.
Cheers
 
Hennepin County, Minnesota 911 Agencies.

PAIN MANAGEMENT – ADULT
To provide relief of pain when indicated. This protocol is NOT to be used in cases where the patient:
• Has a systolic BP less than or equal to 90.
• Has pain determined to be cardiac in origin (See the protocol Ischemic Chest Pain – Adult.).
• Is in active labor.

Standing Orders
A. Assess the patient’s pain on a 0-10 scale or other acceptable method for patients with difficulty communicating

B. Inform the patient that pain is an important diagnostic parameter and the goal of this protocol is to relieve suffering and not to totally eliminate pain

C. Administer one of the following service dependent medications:
1. Morphine Sulfate 2-10 mg (usual effective initial dose 0.1 mg/kg), up to 10 mg single dose IV/IO/IM/SQ. If using IV/IO route titrate in increments to patient response. No maximum total dose of Morphine Sulfate for adults
• Reassess the patient’s pain scale and if necessary administer a second dose up to 5 mg IV/IO/IM/SQ every 5 to 10 minutes. If using IV/IO route titrate in increments to patient response
2. Dilaudid 0.5-2 mg IV/IO/IM. If using IV/IO route titrate in increments to patient response.
• Reassess the patient’s pain scale and if necessary administer a second dose up to 0.5-2 mg IV/IO/IM. No maximum total dose of Dilaudid for adults 3. If pain is of a traumatic origin (non-cardiac), consider Ketamine:
• IV/IO route 0.2 mg/kg (maximum dose 50 mg); may repeat every 15 minutes.
Reassess the patient’s pain scale and if necessary administer a second dose 0.2 mg/kg IV/IO
• IM route 0.4 mg/kg (maximum dose 50 mg); may repeat every 30 minutes.
Reassess the patient’s pain scale and if necessary administer a second dose 0.4 mg/kg IM
4. Inhaled Nitronox may be used as an alternative if available

D. Monitor the patient’s vital signs (including O2 saturation).
If respiratory depression or hypotension occurs after administration of Morphine Sulfate or Dilaudid ventilate the patient as necessary and administer Narcan 0.4-2 mg IV/IO E.

Contact medical control physician for orders if:
• The patient has a systolic BP less than or equal to 90


We dumped morphine about 6 months ago (i Know it was long overdue) and now use dilaudid and ketamine for pain control. I suspect that out use of Ketamine will increase even more. I don't run many 911 calls in my current role, but I havent heard someone with a bad thing to say about the Ketamine use.
 
Texas
Initial dose:
Fentanyl 1mcg/kg
Morphine .1mg/kg
Dilaudid .01mg/kg

No max amounts in protocol. Give what's needed.
 
Clare said:
1) There is no reason for anybody to be in acute pain anymore
2) Pain is bad, so see number 1

The general rule of thumb for us is

Mild pain - paracetamol and ibuprofen in combination,
Moderate pain - above plus oral tramadol and either entonox or methoxyflurane
Severe pain - as above plus morphine or fentanyl
Very severe pain - as above plus ketamine

There are also lignocaine ring blocks but I have never used one nor seen them used.

I really like what is available; lots of tools and it works very well.
Click to expand...

Is the green whistle still in play down there?
http://en.wikipedia.org/wiki/Methoxyflurane
 
We carry fentanyl and morphine.

1-2 mcg/kg fentanyl, call after 300 mug
5 mg morphine, call after 10 mg

We have pretty short transport times, but I've never been shot down calling for more pain meds.
 
I am totally jealous of anyone who was able to list ketamine on here. I also like the New Zealand approach of PO meds.

I work for four ground based services (3 in south MS, 1 in south LA). I will keep it simple.

Job 1, hospital based

Demerol & Morphine. Must (supposed to) call med control for any narcotic. Online physician provides dosing. If med control is unreachable, up to 10mg of MS.

Job 2, hospital based

Morphine and Fentanyl. MS- 2-4mg up to 10 without orders. Fentanyl 25-50mcg up to 200 without orders

Job 3, private service

Morphine & Dilaudid - MS- 2-4mg up to 10 w/o orders. Dilaudid - 1mg w/ orders; must call for each dose.
Toradol is also carried, but orders must be obtained before you ever touch the vial.

Job 4, private service (LA) (also the most liberal)

Morphine & Fentanyl - MS, up to 10mg. Fentanyl, up to 200mcg.



Most services here have moved away from demerol.
 
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