Vitals with pain.

jroyster06

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I'm a huge advoccate of pain management. I give pain meds and give them often. THERE IS NO REASON FOR US TO BE TAKING PT's IN IN LARGE AMOUNTS OF PAIN.

I know a fellow paramedic who is slightly less aggressive with pain management. He believes if they are Normotensive with a normal heart rate they aren't in that much pain and don't require pain management. He states that its impossible to be in large amounts of pain with normal vitals when not taking HTN meds. My argument is that vitals are a small indicator of pain and pt presentation trumps anything else. My further response is how long are we going to see the sympathetic reaction as far as vitals go in the acute onset of trauma or medical pain. Neither one of us have been able to get much past this point. So what are yall's opinions as far as durations of increased vitals due to pain.
 

NYMedic828

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As you already stated every patient is different and every patient will respond differently be it emotional distress or an increase in sympathetic tone.

My view on most things are treat the patient not the numbers. (obviously that is said loosely depending on the cause of the situation)


Unfortunately I am in the same boat as you, except its not just one person. Its every person I work with.


Your patient has severe chest/upper abdominal pain, heart rate of 54 and BP of 110/70. You perform your assessment and rule out an inferior wall MI with a Mobitz II block. Should you withhold pain meds because his vitals are technically stable? (potential for pacing aside)
 
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shiroun

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I'm a huge advoccate of pain management. I give pain meds and give them often. THERE IS NO REASON FOR US TO BE TAKING PT's IN IN LARGE AMOUNTS OF PAIN.

I know a fellow paramedic who is slightly less aggressive with pain management. He believes if they are Normotensive with a normal heart rate they aren't in that much pain and don't require pain management. He states that its impossible to be in large amounts of pain with normal vitals when not taking HTN meds. My argument is that vitals are a small indicator of pain and pt presentation trumps anything else. My further response is how long are we going to see the sympathetic reaction as far as vitals go in the acute onset of trauma or medical pain. Neither one of us have been able to get much past this point. So what are yall's opinions as far as durations of increased vitals due to pain.
I'm nott ALS, so I won't have as much play here.

But I saw an acute lateral femoral fracture, and he was in freaking pain up the butt, yelling, screaming, etc, but had 120/70, 80 BPM. His respirations were a bit shallow, but that was probably from the screaming.
 

DrankTheKoolaid

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I'm a huge advoccate of pain management. I give pain meds and give them often. THERE IS NO REASON FOR US TO BE TAKING PT's IN IN LARGE AMOUNTS OF PAIN.

I know a fellow paramedic who is slightly less aggressive with pain management. He believes if they are Normotensive with a normal heart rate they aren't in that much pain and don't require pain management. He states that its impossible to be in large amounts of pain with normal vitals when not taking HTN meds. My argument is that vitals are a small indicator of pain and pt presentation trumps anything else. My further response is how long are we going to see the sympathetic reaction as far as vitals go in the acute onset of trauma or medical pain. Neither one of us have been able to get much past this point. So what are yall's opinions as far as durations of increased vitals due to pain.
You need to tell your fellow paramedic to educate himself with how pain can effect vital signs.

Some people especially with chronic pain can actually have there BP lowered and become brady in response to acute increase in pain.
 

NYMedic828

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You need to tell your fellow paramedic to educate himself with how pain can effect vital signs.

Some people especially with chronic pain can actually have there BP lowered and become brady in response to acute increase in pain.
That too. Some people have an opposite response and instead of increased sympathetic tone, the pain results in increased vagal tone having the exact opposite effect.

Does not mean they are in any less or more pain than someone else in the same situation with polar opposite vitals.
 

jroyster06

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That too. Some people have an opposite response and instead of increased sympathetic tone, the pain results in increased vagal tone having the exact opposite effect.

Does not mean they are in any less or more pain than someone else in the same situation with polar opposite vitals.


Darnit we need a like button on this forum, haha. I always treat pts not numbers. Do yall have any links or places where i can find good documentation to back me up next time i we get into our debate.
 

NYMedic828

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Not the most credible source, but a reference none the less.

I don't know where people get all the cool articles they find :sad:

http://en.wikipedia.org/wiki/Vasovagal_response

Plenty of people pass out from severe pain ---> vasovagal syncope.
 

jroyster06

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Vasovagal is always a possibility but doesn't happen all that often (In my experience). I am mainly looking for something pertaining to vitals. Im sure someone could continuously vagal down while in pain but im not for certain that is what is happening more often.
 

NYMedic828

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No but people do have vagal responses contrary to the more common sympathetic response to pain. Such would produce opposite vital signs than expected, making vitals an inaccurate indicator of true pain.
 

Veneficus

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I'm a huge advoccate of pain management. I give pain meds and give them often. THERE IS NO REASON FOR US TO BE TAKING PT's IN IN LARGE AMOUNTS OF PAIN.

I know a fellow paramedic who is slightly less aggressive with pain management. He believes if they are Normotensive with a normal heart rate they aren't in that much pain and don't require pain management. He states that its impossible to be in large amounts of pain with normal vitals when not taking HTN meds. My argument is that vitals are a small indicator of pain and pt presentation trumps anything else. My further response is how long are we going to see the sympathetic reaction as far as vitals go in the acute onset of trauma or medical pain. Neither one of us have been able to get much past this point. So what are yall's opinions as far as durations of increased vitals due to pain.
vitals are only one way to assess pain, there are also other clinical signs too look for like muscle tension, sweating, grimacing, answering questions in very few words, the list goes on.

vital signs are only one piece of the puzzle and as stated, may not accurately reflect what is going on. If a pt has apule of 85, is that normal for that patient? What if his resting heart rate is reall 75? How would you know? Same with BP?
 

Doczilla

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After getting my knee crushed by a 400LB. MRAP door, I was sucking. However, my heart rare was 64, and my blood pressure was 118/64.

Thank God they didn't withhold pain meds.
 

the_negro_puppy

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vitals are only one way to assess pain, there are also other clinical signs too look for like muscle tension, sweating, grimacing, answering questions in very few words, the list goes on.

vital signs are only one piece of the puzzle and as stated, may not accurately reflect what is going on. If a pt has apule of 85, is that normal for that patient? What if his resting heart rate is reall 75? How would you know? Same with BP?
This. Assessing patient's pain is a bit of an art form. You can't just rely on certain numbers or the patient saying 10/10. Things to consider-

Appearance- sweating, grimacing, guarding, fidgeting

Speech - are they able to talk to you? are they talking on the phone (lol)

Pain rating - 0-10/10 , mild, moderate or severe? are they comfortable? DO they want something for the pain?

Diagnosis- your own dx and ddx of what the problem may be including visible sings and symptoms, vitals

History- is the patient giving you vague symptoms? are they asking for certain drugs by name (lol) do they have frequent trips to hospital?

We SHOULD be treating pain in the pre-hospital environment. Using the above tools you should be able to work out the best METHOD of treating the pain.

For my service we have-

Splinting, position, elevation, cold pack, slinging
Paracetamol (tylenol)
Methoxyflurane (short acting inhaled analgesic
Morphine IV/IM
Fentanyl IN (children)

We can call for extra assistance-
Midazolam
Fentanyl IV/IM
Ketamine

Pain should be treated but it doesn't have to be Morphine for all pain, neither is P.O tylenol appropriate for severe pain. You can always work your way up. Fractured wrist? I'll try some methoxyflurane. If the patient is still complaining of pain/can't tolerate the smell/taste or won;t use it properly I might consider IV/IM Morphine. This is obviously after splinting etc.
 
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Veneficus

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After getting my knee crushed by a 400LB. MRAP door, I was sucking. However, my heart rare was 64, and my blood pressure was 118/64.

Thank God they didn't withhold pain meds.
Ouch.

(FYI, you are not supposed to stand under the door :) )
 

Doczilla

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More like don't close the door when your leg isn't all the way in the truck, lol.

Beleive it or not, 60mg or toradol had me continuing the mission 30 mins later.

Puppy, I'm jealous that you guys use ketamine in your EMS protocols. A lot of people immediately think "k-hole" when they hear of this magical drug, but sub-anesthetic doses provide profound analgesia , with a serum half life of about 8 hours.

JSOC's medical committee is talking about using ketamine more extensively, at doses of around .25-.50 mg/kg.
 

VFlutter

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Also patients with chronic pain will most likely have "normal" vitals even when their pain is exacerbated as well as possibly a tolerance to various pain medications. That is no excuse not to provide analgesia
 

the_negro_puppy

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More like don't close the door when your leg isn't all the way in the truck, lol.

Beleive it or not, 60mg or toradol had me continuing the mission 30 mins later.

Puppy, I'm jealous that you guys use ketamine in your EMS protocols. A lot of people immediately think "k-hole" when they hear of this magical drug, but sub-anesthetic doses provide profound analgesia , with a serum half life of about 8 hours.

JSOC's medical committee is talking about using ketamine more extensively, at doses of around .25-.50 mg/kg.
Our indications are for significant pain (after morphine given ) for

- Fracture reduction or splinting
- Multiple or significant fractures requiring facilitated extrication
- Severe traumatic pain from burns

Dose is 10-20mg every 2-3 minutes max 1mg/kg
 

MSDeltaFlt

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As far as traumatic injury goes pain management tends to be a bit more simple than interpreting medical pain. Especially if your medical pain calls come from your seekers. Because you can just ignore their complaints simply because they're known addicts. That's where it truly does become an art form.

However, I am a big proponent of the philosophy: "Treat the cause and you'll treat the symptom".
 

AnthonyM83

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Some people dissociate mentally when in pain which might keep their vital signs low. They're still feeling it, just actively working hard to ignore it and get lost in their minds (thus why they might not be the best at answering your assessment questions).
 

KellyBracket

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Most of the medical evidence suggests that the correlation of pain level with elevated pulse & BP is a myth. Of course, due to the subjective nature of the phenomenon in question, it is hard to answer the question directly.

In the prehospital literature, The reliability of vital signs in estimating pain severity among adult patients treated by paramedics found that there was no correlation between self-reported pain and VS. A more recent study, Prehospital vital signs can predict pain severity: analysis using ordinal logistic regression, does suggest such a link, but the results seem to be clinically dubious. For example, they state that "a heart rate of 100 beats/min or more was associated with 18% increased odds of more severe pain (P<0.0001)." Given that they studied over 53,000 run sheets, it seems likely that this is a statistical association fueled by the large n, and difficult to apply to the individual patient.

Well, how about a standardized pain stimulus? My med school mentor looked at ED patients having an IV started, and tried to correlate their levels of pain and anxiety with VS. In his paper Heart rate response to intravenous catheter placement. he found that there was no such correlation. They concluded "These data illustrate that monitoring of a patient’s heart rate is not a reliable indicator of the amount of pain that he or she is experiencing. Making the assumption that a patient is not in significant pain because of a lack of tachycardia might lead erroneously to inadequate treatment of significant pain."

There are other studies out there, but this is the gist.
 
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