What pain management options do you have?

Aidey

Aidey

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With the recent discussions on pain management I'm curious what options people have available to them to manage pain. So...

What meds do you carry?
What non-narcotics are available for pre hospital use?
Anyone using IV muscle relaxants that are not benzos?
Anyone using PO meds?
Do you have a protocol for conscious sedation?
 
Fent 0.5 mcg/kg for injuries and suspected kidney stones, 1 mcg/kg for Cx discomfort w/ cardiac etiology, both standing orders.

Versed for cardioversion and pacing, 2 mg standing orders.

Zofran for N/V, 4 mg IVD mixed in 100 cc NS, 10 gtt set, wide open, or 4 mg P.O. S.O. Not pain management per se, but certainly a comfort measure.

O2, cold packs, and vacuum splints, which help greatly w/ immobilizing extremities and allowing us to move the pt w/ greatly reduced pain, or even no pain whatsoever.

No RSI. We have our medevacs and also Fairfax City txp crews that can do it if we request it. QA/QI issues and close proximity to area hospitals are the reason I'm given for no RSI at my dept.

Edit: Forgot, morphine for injuries, stones, and cardiacs, 1-10 mg, can call for more w/o any issue, usually.
 
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Methoxyflurane, paracetamol and unlimited entonox, morphine, midazolam and ketamine.

We have conscious sedation and RSI.

All are written Guidelines with no base hospital contact required, not that we have ever had that anyway!
 
Our options are:

Fentanyl 1-2mcg/kg prn for pain, up to 3mcg/kg for sedation or induction.

Ketamine 1.5mg/kg for pain, sedation, and induction.

Morphine 0.05-0.1mg/kg prn.

We have Ketorolac available for IM and IV use.

Vesed and/or Ativan for sedation, anxiety, or muscle relaxation.

Reglan, Zofran, and Phenergan for nausea / comfort.
 
I'm guessing that you guys don't hire 12 week Parathinktheyare's and Medicfighters from the Paramedic patch factory for the barely homeostasasing if you use all those meds :D
 
Methoxyflurane
Inhalant. 2x3ml doses. Great for quick relief before cannulation or for procedural pain like a reduction or moving onto a stretcher, putting a splint on etc.

Morphine IV/IM
Up to 20mg (anymore requires a consultation with a more experienced medic). No limit for Intensive Care paramedics.

Fentanyl IN
200mcg first dose, 4 x 50mcg q5. Paeds: 2mcg/kg, 2 x 1mcg/kg q5 (IV at Intensive Care level, 25-50mcg boluses).

Ketamine is being trialed at IC level in some places. Don't know much about it.

We have lignocaine, but its only there for combination with IM ceftriaxone when you can't get IV access. Needless to say, that doesn't happen too much.

I wish we had an NSAID, an option for combining Midaz and morpine, and IV fent at the basic level. OTC PO meds are only an option if the person happens to have some at their house, not to many medics use that option, but some do.

We have conscious sedation at IC level but not for pain relief.
 
MrBrown said:
I'm guessing that you guys don't hire 12 week Parathinktheyare's and Medicfighters from the Paramedic patch factory for the barely homeostasasing if you use all those meds :D
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Nope, not a chance in he!!........

We do not even consider applicants with less than 3 years quality experience.
 
Fentanyl is our front line., 1-2mcg/kg q 10

If that's inadaquate, we can (after med control consult) combine it with midazolam/lorazepam 0.5-2mgs of either. Either of these can also be used as a stand alone for agitaion

I've carried nitronox at one service, and I miss it greatly. However, from what I understand they don't make the blenders anymore, and the FDA has a hissy fit over single bottle Entonox.

Zofran is currently our only antiemetic, due to some wundermedics who didn't understand the concept of dilution.

I'd love to see more pain management options like APAP, hydromorphone (for certain situatons) and Toradol. I am pretty satisfied with what we can do to sedate. Our antiemetic option sucks once they've actually puked, Reglan, or even including diphenhydramine (old school) for N/V refractory to Zofran would be nice. Overall though, our service has just recently started making pt comfort a concern, a year ago pain control was limited to 0.04mgs of morphine for extremity trauma or burns, nothing else. So we've improved vastly. I see this trend continuing, as our medics, patients and med control have all been very satisfied. Now if we could just get our outlying hospitals to understand why we do this.
 
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We have Ketamine, Fentanyl, Nitrous Oxide all great choices foer different situations
Versed and Valium but would like to Ativan
 
I have to ask, what service in NM used Nitrous? Or Ketamine for that matter? I'm just curious, since I've never heard any of the flight medics I know for SW or TSCF say anythign about those.
 
We knock them out by hitting their head with a stone.
 
usalsfyre said:
F Overall though, our service has just recently started making pt comfort a concern, a year ago pain control was limited to 0.04mgs of morphine for extremity trauma or burns, nothing else. So we've improved vastly. I see this trend continuing, as our medics, patients and med control have all been very satisfied. Now if we could just get our outlying hospitals to understand why we do this.
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0.04mgs of Morphine...? Even for the US that has gotta be a typo :P

What don't the hospitals understand?
 
Nope, no typo we used to give a 100 kilo patient 4mgs of morphine, one time. Kind of the equivilent of putting a bandaid on a severed limb...

There are two large services in our area. One affiliated with one major health system, the other with the two other major health systems (the one I work for). As I said, service two recently did a major protocol overhaul, and pain managment is high on that list. What went along with this has been about 75 hours of additional CE spread out over the year, helping to bring all of our medics (even the low performers) up to a minimum level of practice.

Service one on the other hand, practices next to no pain management. The only option available to them is 2mgs of nalbuphine, given only for "extreme" pain (their words not mine). There's also a smattering of smaller services that practice typical 1990s EMS pain management.

The result of all this is the doc in the boxes dislike prehospital pain management, for all of the tired old reasons. The local hospital that I transport to pretty much balls me out everytime they I bring them a patient with meds on board. Which has resulted on me, my supervisor, and my clinical and medical director placing them on the ignore list. There's still a lot of education about EMS best practices to be done among the crowd that hangs around little rural EDs.
 
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Morphine: 2-4mg up to 20mg without calling.
Fentanyl: 25mcg, up to 200 mcg without calling.
Ketorolac: 50mg for kidney stones.

We also carry Valium, Versed and Ativan for sedation and/or anxiety, as well as Droperidiol, Phenergan, Zofran and Diphenhydramine, which we may use as an antiemetic or sedation as we see fit.
 
Fentanyl 1 mcg/kg IV/IM/IN. May repeat 0.5 mcg/kg every 5 minutes to a max of 300 mcg.

Tylenol.

Ibuprofen. However its only indication is for fever.

Midazolam to piggyback an analgesic if needed.

Diazepam to piggyback an analgesic if needed.

I'm not a huge fan of fentanyl. Just doesn't get the pain control that morphine achieved. I miss when we could give morphine and phenergan. The combo of those two made for great pain control.
 
n7lxi said:
Morphine: 2-4mg up to 20mg without calling.
Fentanyl: 25mcg, up to 200 mcg without calling.
Ketorolac: 50mg for kidney stones.

We also carry Valium, Versed and Ativan for sedation and/or anxiety, as well as Droperidiol, Phenergan, Zofran and Diphenhydramine, which we may use as an antiemetic or sedation as we see fit.
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Toradol for kidney stones? I've had over 20 in my life and just about every time some ER doc tries to use that garbage. Doesn't work for me. Do they allow you to administer MS of fentanyl in adition to toradol?
 
Fentanyl, Toradol, Lidocaine, Versed, Morphine, and Haldol. Dilaudid is approved but I do not believe we carry it.
 
LonghornMedic said:
Toradol for kidney stones? I've had over 20 in my life and just about every time some ER doc tries to use that garbage. Doesn't work for me. Do they allow you to administer MS of fentanyl in adition to toradol?
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Luckily, our docs believe in pain management and and trust the medics. So, if I had a case with a patient that presented with kidney stones and a history of the same and told me that Toradol hadn't touched his pain in the past, I'd have no problems getting orders for MS or Fentanyl. We have long transport times, upwards of 40 minutes, so I'll do what I can to make the patient comfortable.

As an aside, I've also had kidney stones (it sucked) and the combo of Ativan and Toradol worked for me. :)
 
Toradol works wonders for biliary pain as well, from past experience :)
 
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