What is your opinion of pain management?

[RocketMedic]

"Patients only remember two things- were you nice, and did you make the pain stop"- a mentor.

One of the most common expectations of EMS is that we make the situation better, which to many people and patients means effective pain management as a component of care. Our ability to provide effective pain management (be it via non-pharmecutical or pharmaceutical means or a combination of the two) is one of the few things that differentiates us as a medical service from a transportation service in the minds of our customers.

With that being said, what is your personal take on pain management and its importance in prehospital or out-of-hospital care? (Many of us have protocols allowing it, but it is our discretion to implement them, hence why it's a personal question). How did you come to this viewpoint?

Speaking of protocols, are you sufficiently empowered in your opinion to meet the expectations of your community, your patients and your receiving facility? Are your protocols inadequate, adequate or overly generous? What would you want to change?

 

[Clare]

Pain is bad and should be relieved. That's about it really. Obviously you have to be sensible about it, I mean if somebody had low blood pressure then you just have to be more careful and give smaller doses or some fluid in addition to morphine or whatever, or better yet, use fentanyl!

We have the following pain relief

EMT: Paracetamol, ibuprofen, tramadol, entonox, methoxyflurane
Paramedic: All of the above plus morphine, fentanyl and lignocaine blocks
ICP: All of the above plus ketamine and midazolam (noting midazolam has no pain relieving properties but can be used in severe muscle spasm etc)

If somebody is in pain they need pain relief until they are no longer need it. I have spent lots of time on scene with people in pain getting them treated well enough otherwise we couldn't move them.

I don't really like entonox only because the cylinder is not very practical to carry around in addition to everything else but it's not a problem once the pt is on the bed because you can put it between their legs or on the back if you sit the head end up.

I have never had a situation where it was not possible to relieve somebodies pain and I really cannot think of one either. If they have low blood pressure give fluids and use small boluses of fentanyl, if they do not want morphine, use fentanyl, if they cannot have entonox, use methoxyflurane etc.

What is pain relief like elsewhere? I read that in US you don't have entonox. I can't believe it why not? I mean, how do you give pain relief without it if you do not have morphine or the patient doesn't need it? Like somebody with a simple fracture who doesn't need morphine?

 

[EpiEMS]

.Our ability to provide effective pain management (be it via non-pharmecutical or pharmaceutical means or a combination of the two) is one of the few things that differentiates us as a medical service from a transportation service in the minds of our customers.

100%, but when you look at your average BLS service in the bulk of the U.S., or even just your BLS unit in an ALS system, the BLS unit is limited to a few pain control measures, most of which won't really address the problem for quite a large number of common conditions.

If you look at the national scope for the EMT, pain control measures are:

- Splinting (incl. traction splinting)
- Ice & heat packs (this isn't *explicitly* in-scope, but there's no state protocol I'm aware of that would prohibit it)
- The stare of life / soothing words
- ALS intercept

I would argue that there are certainly pain control measures that could be introduced at the EMT-level, and certainly should be part of the national scope. For example, the addition of PO ibuprofen and/or PO acetaminophen, as some protocols have done, could be a beneficial intervention at low risk. Similarly, while entonox/nitrous isn't used in many systems, I can't see why adding it to the EMT scope (as it's already in the AEMT national scope) would be terribly harmful. On the more liberal end, how about pain control with...IN ketorolac?

This being said, for many BLS-level agencies, especially those where ALS and/or a hospital is a close drive, the value-add from the limited-risk pain control measures I suggest may be minimal. However, for those systems where the drive might be a bit longer, I can't imagine too much downside.

The U.S. is clearly behind the times -- pain is bad, and we should try and see what measures can be pushed down to BLS providers to relieve it. I would be wary of suggestions like introducing morphine autoinjectors in most systems, mainly owing to the logistical issues, but I can't imagine too much of a downside with sufficient OLMC direction.

 

[cruiseforever]

I feel that pain should be treated aggressively. The biggest issue our medical directors have is how to treat a chronic pain issue. For the last few years we treated most pain fairly aggressive. Now there is a big push to still treat acute pain aggresively, but to limit the use of medications to treat chronic pain.

We can pick from, Morphine, Fentanyl, Dilaudid, Ketamine on standing orders.

Need to get med. control for Versed to help with pain management. Still hoping to get that changed in the next year. Had a procedure last year and was given Fentanyl and Versed. What a wonderful combination.

 

[NYBLS]

A subject I'm very interested in. For those posting what drugs you carry would you mind posting how much you carry? Curiosity on my part.

 

[luke_31]

We carry 20mg morphine, 2mg dilaudid, 10mg versed, and 10mg Valium. We can administer 10mg morphine, 2mg dilaudid without orders, and can administer either the verses or Valium for seizures without orders and have to call for sedation. But we also carry haldol for combative patients

 

[chaz90]

Our pain management policy is fairly constrained based on what we carry, and our pharmacological choices are extremely limited. We carry 400 mcg Fentanyl and 10 mg Versed. That's it. There have been discussions about getting Ketamine, but I've heard no rumors of anything else like Ketorolac or any alternative opioids or benzos.

Some variety of PO analgesic wouldn't be the worst idea, even though I understand the argument that if the pain is that minor it likely doesn't need intervention by EMS. I would like to be able to offer something to our patients that have pain that doesn't reach the level of needing narcotics but could still benefit from some type of relief. It would also be nice to have something to administer to patients that really don't want opioids for whatever reason.

If we only had to carry one opioid analgesic I'm certain Fentanyl would be the one to choose, but I really believe we would benefit from having some Dilaudid to use as an alternative during some of our extremely long transports. Multiple administrations of small doses of Fentanyl during an hour long transport across country roads can get tiresome.

 

[Clare]

We carry paracetamol, ibuprofen and tramadol tablets. I do not know the exact number but probably 100 of each. We also have paracetamol liquid in a container you fit the syringe into the top and draw it up so there is no mess, its awesome.

Entonox is a single cylinder that is the same size as portable oxygen, i think from memory its a couple hundred litres. Methoxyflurane one kit is carried in the first response bag and one in the ambulance.

Each officer carries 30 mg of morphine, 200 mcg of fentanyl and ICPs also carry 400 mg of ketamine.

 

[cruiseforever]

A subject I'm very interested in. For those posting what drugs you carry would you mind posting how much you carry? Curiosity on my part.

Depends on the area that I am working in. But the most common amounts are: Morphine 40 mg, Fentanyl 200 mcg, Dialudid 4 mg, Ketamine 1000 mg, Versed 40 mg.

For trauma we have no limits on the amount of Morphine, Fentanyl is 200 mcg, Dialudid is 2 mg, Ketamine is a max of 50 mg, need to call med control if we want Versed or more Ketamine.

Cardiac we are limited to 10 mg morphine without med control.

Other medical conditions we can default to the trauma doses.

 

[teedubbyaw]

Unfortunately, it's hard to please everyone when Fentanyl is the only decent pain management medication we carry.

 

[Carlos Danger]

Honestly, I'd be happy with nothing but fentanyl in the field. It is hands down the most useful analgesic for prehospital use. More bang for your buck than anything else.

Ketamine is a good option to have available but IMO is not better than fentanyl in 95% of cases of severe pain.

Dilaudid is a great drug but it's long onset makes it hard to titrate and it's long duration and potent respiratory depressant effects means that accidentally giving too much can cause problems. So it's utility is limited primarily to long transports, but even then I'd probably rather use fentanyl most of the time.

Morphine is just a lousy drug compared to fentanyl or hydromorphone. All the downsides of dilaudid magnified - plus several downsides that don't exist with dilaudid. I never use morphine for anything.

The potent fentanyl analogues (sufentanil, alfentanil) are great but not better than fentanyl for routine use. Alfenta has some interesting, almost neurolept anesthetic-like properties that are useful in some settings.

Ketorolac is a great adjunct to opioids but alone is only really effective in certain types of mild-moderate pain. Importantly, it is contraindicated (or relatively so) in many patients - basically in anyone sick, you should think twice about using it. This makes it not a great drug for prehospital use, IMO.

IV acetaminophen, like ketorolac, only works as an adjunct to opioids if pain is severe. It is a good option in less severe pain, but it has a relatively long onset time. It is also currently only available in glass bottles.

PO NSAIDs have too long an onset time to be useful in the prehospital setting, and are only useful in certain types of pain.

Gabapentin, pregabalin, tramadol, phenytoin, and the other reputake inhibitors and antiepileptics are primarily used in the management of chronic pain and may have some role in certain types of acute pain, but as of now are not appropriate for prehospital use.

Certain miscellaneous adjuncts like esmolol, dexamethasone, lidocaine, magnesium, clonidine, antihistamines, etc. can probably be useful in some situations but require a more thorough understanding of pain physiology and pharmacology, and have never been experimented with in the ED or EMS settings, that I am aware of.

Dexmedetomidine is a great drug that I loved using (don't have it where I am now) but I don't foresee it becoming common in the prehospital arena anytime soon.

You hear a lot of paramedics talk about using benzos as an adjunct to opioids in severe pain but I don't think that's a great practice. You can read about anxiety aggravating nociception in some patients but generally they are separate problems, so if someone is really freaking out despite a decent dose of opioids, versed might be a good option but understand you are using the versed to treat their anxiety, not to potentiate the opioid. Generally, more opioid is the answer.

So, IMO fentanyl is really where it's at. Dilaudid and ketamine are good to have in the drug box as options, but I'd rarely use them. That's just my 2 cents.

 

[teedubbyaw]

I agree that it's good for our use, but I'll be happy when Ketamine comes into our pain management protocols next year.

 

[MonkeyArrow]

Certain miscellaneous adjuncts like esmolol, dexamethasone, lidocaine, clonidine, antihistamines, etc. can probably be useful in some situations but require a more thorough understanding of pain physiology and pharmacology.

Can you explain esmolol? I thought it was a beta blocker used mostly in cases of aortic dissection.

Also, I don't really understand why people are carrying dilaudid on ambulances. Hell, our ED medical director doesn't like patients being given hydromorphone and the trend is really to move away from it as soon as possible post-op, so I really don't understand why people carry it pre-hospitally. It is, as I understand, one of the most potent analgesics, with a long duration and not able to be titrated. Why someone would push something so strong pre-hospitally when you can just give fent (for short transports) or set up a fent drip (for longer transports) is beyond me.

 

[Carlos Danger]

Can you explain esmolol? I thought it was a beta blocker used mostly in cases of aortic dissection.

There are several theories, ranging from a reduction of hepatic opioid metabolism to activation of g-proteins that are involved in nociception to making the blood-brain barrier more permeable to opioids, to a central opioid-like mechanism involving inhibitory neurotransmitters in the spinal cord.

http://journals.lww.com/_layouts/OAKS.Journals/ePDF.aspx
http://www.aana.com/newsandjournal/20102019/060115roleesmololperianalgesia.pdf

Also, I don't really understand why people are carrying dilaudid on ambulances. Hell, our ED medical director doesn't like patients being given hydromorphone and the trend is really to move away from it as soon as possible post-op, so I really don't understand why people carry it pre-hospitally. It is, as I understand, one of the most potent analgesics, with a long duration and not able to be titrated. Why someone would push something so strong pre-hospitally when you can just give fent (for short transports) or set up a fent drip (for longer transports) is beyond me.

Dilaudid is a great drug and I think it definitely has a role prehospital, but you do need to be careful with it - it is certainly less forgiving than fentanyl.

 

[Clare]

Honestly, I'd be happy with nothing but fentanyl in the field

Coming from an anaesthetist I am quite surprised by this given it's the medical speciality who deal most with pain (both acute and chronic). I am sure not all of your patients get fentanyl and nothing else in the hospital for their acute pain so why should it be any different prehospital?

What about entonox or methoxyflurane? Entonox is spectacular for patients who only have moderate pain and who don't need morphine or fentanyl. If you can't have entonox for whatever reason then there's methoxyflurane as an alternate. I have personally never used methoxyflurane but it's used by every ambulance service in Australia so it must be doing something right.

The addition of tramadol oral has been great in the ambulance, again I've seen amazing results with it. Quite a few people with pain that would have otherwise received morphine can be managed with paracetamol, ibuprofen and tramadol in combination with entonox. It's great for double EMT crews from the volunteer stations who might be a long way from hospital or backup as well. Gives them something a bit stronger.

Paracetamol and ibuprofen in combination are great for mild pain, especially in kids.

 

[Carlos Danger]

Coming from an anaesthetist I am quite surprised by this given it's the medical speciality who deal most with pain (both acute and chronic). I am sure not all of your patients get fentanyl and nothing else in the hospital for their acute pain so why should it be any different prehospital?

What about entonox or methoxyflurane? Entonox is spectacular for patients who only have moderate pain and who don't need morphine or fentanyl. If you can't have entonox for whatever reason then there's methoxyflurane as an alternate. I have personally never used methoxyflurane but it's used by every ambulance service in Australia so it must be doing something right.

The addition of tramadol oral has been great in the ambulance, again I've seen amazing results with it. Quite a few people with pain that would have otherwise received morphine can be managed with paracetamol, ibuprofen and tramadol in combination with entonox. It's great for double EMT crews from the volunteer stations who might be a long way from hospital or backup as well. Gives them something a bit stronger.

Paracetamol and ibuprofen in combination are great for mild pain, especially in kids.

First, I am very much of the K.I.S.S. school of thinking. We can do things lots of different ways but I prefer the simplest in almost every case. You just don't need a ton of different drugs.

A patient with acute pain in the prehospital setting is a very different animal than someone having a painful procedure done, or a post-op patient, or an ICU patient. Because they are different, they get managed differently, with different drugs. There are lots of things that I do in the OR and PACU that are simply not relevant to the prehospital setting. For instance, we use gabapentin pre-op for some OR cases, and clonidine in nerve blocks. That doesn't mean those are necessarily good drugs to give in an ambulance.

Fentanyl is potent, predictable, fast, forgiving, titratable, and has few side effects.....much more so than ketamine or the longer lasting opioids (morphine, hydromorphone, meperidine) or anything that can be given PO. It is the perfect EMS analgesic.

Entonox and methoxyflurane are not widely available in the US. I have never used either, nor do I remember them even being mentioned at any point in my training, either as a paramedic or CRNA.

Tramadol is a weak opioid and reuptake inhibitor. The serotonergic effects take several doses to become pronounced, so they are not a factor in the prehospital setting. All you are left with with is a weak opioid that takes at least 30 minutes to even start working, and an hour to take full effect. I don't see that as having any role in the prehospital setting, where my goal is to get pain under control now. Plus, with antidepressants being so commonly used in the US, there is polypharmacy to consider in giving a serotonergic and norepinephrinergic drug. I'm not sure how it is where you live, but consumers of EMS services in the US tend to be on lots of meds.

For mild pain, sure, ibuprofen and/or acetaminophen are great. As an adjunct to opioids, I don't see their effects being all that valuable in the field, owing largely, again, to their long onset time.

Edit: I just realized you probably have IV tramadol. I have never used or even seen it; only the PO version is common here.

 

[EMTinCT]

Had a PT who was trapped in a vehicle from a head on collision. She was screaming in horrible pain due to her legs being crushed and the wreckage from the car pinning them. We're BLS and couldn't do anything for the pain during the 1hr it took for the FD to cut her out. Even after we got her on the ambulance it took another 40 minutes to get to the closest ER which isn't a trauma facility but at least they have a helicopter landing pad. No ALS service is available to us as we're that far in the boonies. If you had been an EMS medical director and in such an accident I guess you'd become a proponent of BLS-level pain control.

 

[Flying]

Had a PT who was trapped in a vehicle from a head on collision. She was screaming in horrible pain due to her legs being crushed and the wreckage from the car pinning them. We're BLS and couldn't do anything for the pain during the 1hr it took for the FD to cut her out. Even after we got her on the ambulance it took another 40 minutes to get to the closest ER which isn't a trauma facility but at least they have a helicopter landing pad. No ALS service is available to us as we're that far in the boonies. If you had been an EMS medical director and in such an accident I guess you'd become a proponent of BLS-level pain control.

As much as I would like to be able to provide methoxyflurane to patients, a better case could probably be made for paying for an ALS intercept service in your area.

 

[Tigger]

I would like to see something to bridge the gap between opioid analgesia and positioning measures. Our transport times are sometimes long, and realistically the patient with minor to moderate pain is not going to be medicated in the ED quickly, so I see some use in medications with a longer onset. Toradol works for many patients, but as noted is not often a great choice for the chronically ill. Nitronox exists and is reasonably safe, but is big/bulky and expensive.

Fentanyl is our go to here (400mcg onboard, 1-3mcg/kg with no max dose). We also carry Ketamine (500mg on board), and Morphine (40mg). Versed (10mg) and Valium (20mg) can be given for spasm and as an anoxilytic, though our medical director prefers Ketamine be used first.

 

[EMTinCT]

As much as I would like to be able to provide methoxyflurane to patients, a better case could probably be made for paying for an ALS intercept service in your area.

That's the thing, we are an all-volunteer department with fewer than 200 calls a year. Paying for ALS intercept isn't possible. We barely have enough money to keep diesel in the ambulance so paying for a medic can't happen. In addition there is no ALS service for just over 50 miles so even if we paid for it the timing makes it impossible.

These are the realities of rural, volunteer EMS that ought to change how things are done and influence how decisions are made. At least that's what grandma says.