Pain Management for Pre-hospital Professionals

2nd Trimester May 2011 CME

By Silver Cross EMS Staff

Pain and EMS

• Whether our patients are suffering from a traumatic, medical or psychological condition, a common thread throughout many of our calls is pain.

• Definition from the International Association for the Study of Pain: “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage…”

Pain Serves a Purpose

• It tells us something is wrong with our body that we can’t see otherwise– Appendicitis– Internal bleeding

• It helps us avoid dangerous things– We touch a hot stove, we feel pain, we pull away

• It helps us protect damaged body parts– We shield injuries from accidental contact with

other people or things

What Causes Pain?

• Pain signals are sent to our brain by nociceptors (no-si-sep-tors)

• A nociceptor responds to damaging stimuli (heat, pressure, etc.) by sending nerve signals to the spinal cord and brain.

• This process, called nociception (no-si-sep-shun), is what causes the feeling of pain.

The Pain Pathway (tutorvista.com)

Classifications of Pain (from Mosby’s Paramedic textbook)

• Acute – sudden in onset, subsides with treatment

• Chronic – persistent or recurrent, hard to treat• Referred – pain felt somewhere other than its

origin– Heart attack felt in arm– Spleen rupture felt in shoulder– Gall bladder felt in shoulder blade

Classifications of Pain (from Mosby’s Paramedic textbook)

• Somatic – pain in muscles, ligaments, vessels, joints

• Superficial – pain in skin, mucous membranes• Visceral – “deep” pain, hard to localize, arises

from smooth muscles or organ systems

Some other kinds of pain

• Neuropathic – caused by damage or disease to the nervous system– Tingling, burning, electrical “zapping” – “Pins and needles”– Bumping the “funny bone”

• Psychogenic – caused by mental, emotional, or behavioral factors– No less hurtful than pain from other sources– Not “all in their head”

Phantom Pain

• Phantom – felt after limb is amputated– Nerve endings to stump become “confused”– Signal pain to the brain even though the limb is no

longer there.

Inability to Feel Pain

• Some people can’t feel pain like they should– Diabetic neuropathy– Spinal cord injury– Congenital disorders

• More prone to injury due to lack of “warning”• May be shorter life span due to increased

injury risk

Pain Tolerance

• Several studies over the years have shown women typically display lower pain tolerance than men.

• Unknown whether reason is hormonal, genetic or psychosocial.

• Researchers suggest men more tolerant of pain because of “macho” stereotyping, while feminine stereotyping encourages pain expression.

Pain Tolerance

• On the other hand, the show “Mythbusters” recently found women to be more tolerant of pain than men, so stereotypical responses may be changing over time.

The Bad Side of Pain

• While pain serves an important purpose, it also presents a barrier to normal functioning

• Pain negatively affects:– Attention– Memory– Mental flexibility – Problem solving – Information processing speed– Stress levels

Pain Management

• Because pain has as many bad aspects as good, our goal in EMS is to control pain whenever possible.

• Joint Commission (JCAHO) says pain is 5th vital sign after BP, pulse, respiratory, and temp.

• The goal – ZERO PAIN!

Why Zero Pain?

• Cardiac chest pain – zero pain means less stress on the patient, lowering pulse and BP, leading to less work for the heart

• Musculo-skeletal pain – zero pain means your patient is more cooperative, less disruptive and better able to follow directions

When is zero pain not the goal?

• There are a few times in EMS when we don’t want to treat pain– Headache – pain medication can mask symptoms

of a more serious head injury– Abdominal pain – pain location is often used for

diagnosis of new-onset abdominal pain– Drug-seeking patient – trust your instincts• If you suspect patient is a drug-seeker, let medical

control know your suspicions (out of earshot of patient)

EMS and Pain

• Prehospital Emergency Care, Jul-Sep 2010… pain in prehospital emergency medicine affects 42% of patients…. Pain management is inadequate, as only one in two patients experiences relief.”

• American Journal of Emergency Medicine, Oct 2007… “women are less likely than men to receive prehospital analgesia for isolated extremity injuries… Increasing levels of income were associated with increased rates of analgesia.”

Why are we not treating pain adequately?

• Biases and prejudices?– Poor patients, patients we think are faking it, patients who are

“whiners”• Fear of medication administration?

– Giving narcotics is a big responsibility, especially if we are not comfortable with our skills and math ability

Why are we not treating pain adequately?

• Our own emotional reaction to someone in pain?– Our anxiety can cloud our judgment regarding treatment– A screaming patient makes even the best medic second-guess

• Past issues with medical control regarding medication administration?– In the old days, paramedics often got hassled for attempting ALS pain

management. Sometimes, they still do.

Assessing Pain

• The most basic way to characterize pain is the 1-10 scale (some use 0-10).

• All reports/narratives with patients in pain should include a 1-10 rating both before, and after, treatment– 1 (or 0) = no pain– 10= worst pain ever felt

Assessing Pain

• For children and others with difficulties understanding the 1-10 scale, you can use the Wong-Baker scale– Also called the “smiley face” scale

• They point to the picture that best describes their pain.

Wong-Baker Scale

Assessing Pain - OPQRST• All narratives for pain and injury should

include some form of OPQRST• O – Onset (when did pain start)• P – Palliation/Provocation (what makes it better or worse)• Q – Quality (what does it feel like)• R – Radiation (does it move anywhere)• S – Severity (1-10 scale)• T – Time (can be combined with O, or can refer to whether it

comes and goes or is steady)

OPQRST

• You don’t have to specifically reference each letter in your report. – Like any mnemonic, it’s more to help you

remember important assessment questions, than to actually be used word-for-word.

• But if the information is relevant, it needs to be included somehow.

Assessing Pain

• What does patient look like?– Obvious distress?– Guarding injured limb?– Yelling?– Calm and controlled?– Tense?

Assessing Pain

• Remember DCAP-BTLS?• All painful or injured body parts need to be

exposed and examined.• And all examinations need to be documented.– Exception – obvious cardiac chest pain, but if you

are putting on EKG leads, you might as well examine and document anyway since you are there.

Assessing Pain – Head-to-Toe

• Depending on the mechanism of injury or the nature of the illness, a head-to-toe exam may be called for too.

• Document all head-to-toe exams. If it’s not written down, it wasn’t done.

• Don’t let severe pain from one part of the body distract you from injuries on other parts of the body.

Assessing Pain - Peds

• Sometime starting at the toes and working your way up to the head works better with kids.– May be less likely to freak out.

• Kids are the kings and queens of distracting injuries. – They don’t understand why a bloody finger is less

important than a deformed leg.– Take extra care in examining a child in pain

Pain pharmacology/treatment

• Pain medications/treatments address two components of pain:– The actual sensation of pain– The emotional response to pain

• We carry medications and treatments on the ambulance that address both components

• Don’t forget BLS treatments… often just as effective as ALS medications, and easier too.

Cold Packs

• Cold packs often a forgotten element of pain management.

• Reduce swelling and pain in strains, sprains and fractures.

• When possible, do not put directly on injured area.– Can cause tissue damage– Wrap in pillow case or gauze first

Splinting

• Splinting used to stabilize damaged bone ends, or injured muscles/ligaments.

• But also useful in reducing pain caused by movement of injured areas.• Whether a commercial splint, or a pillow and tape… a

splint is powerful weapon against pain.• Traction splint significantly reduces pain of femur fracture

by easing muscular contraction

• Check distal pulses, movement and feeling (“MSC”, “CMS”, “PMS”) before/after splinting.

Opiates• Bind with opiod receptors in the brain– Alters perception of pain– Alters emotional response to painful stimulus

Drugandalcoholrehab.net

Morphine

• Commonly carried by EMS• Chief alkaloid of opium• Carried by prehospital crews because– It’s cheap– It’s been around a long time– It works without too much fuss– It’s easy to treat if we give too much of it (Narcan)

Morphine side-effects

• Respiratory depression• Nausea/vomiting• Constipation• CNS depression• Careful administration can prevent many of

these side-effects

Morphine dosage

• Suspected cardiac– 2-10mg IVP in 1-2mg increments as needed for

severe chest pain– No permission from medical control necessary,

but call with questions or concerns– Morphine reduces pain, stress, work of the heart– Used in conjunction with nitro, can easily meet

goal of ZERO PAIN in suspected cardiac patients

Morphine Dosage

• Traumatic injury/burn• 5-10mg slow IVP in 5mg increments as

necessary for pain– Exception is crush injury – 2mg increments IV/IM

as needed for pain

• Permission from medical control not necessary, but call with questions or concerns– Call first if patient has respiratory depression,

bradycardia or is hypotensive

Morphine and Kids

• Kids deserve ZERO PAIN pain too!• Pediatric morphine dose for fractures or

burns:– 0.1mg/kg (max of 5mg per dose)– Or use length-based pediatric tape (Broslow)– Newborns and young babies don’t get morphine

• Call Medical Control before giving morphine to kids

Morphine and Allergies

• Don’t give if allergic to morphine or other opiates/opiods.– Be aware: morphine can cause a small histamine

release in patients not normally allergic to it• Flushed skin• Itchy nose/skin

• Allergy to sulfa drugs not a contra-indication to Morphine Sulfate administration– Sulfa and Sulfate are not the same thing (not even

close!

Non-narcotic Analgesics

• The only non-narcotic analgesic we carry on the ambulance is aspirin.

• And ironically, we don’t give aspirin for pain. We give it to suspected cardiac patients, as aspirin is linked to better outcomes for these patients– May be due to its anti-clotting properties.

Anesthetics• Anesthetics are CNS depressants.– Act on nervous tissue

• Two main anesthetics in Silver Cross EMS system– Tetracaine – local anesthetic• 1 to 2 drops as needed for hazmat eye exposure

– Nitrous oxide – inhaled anesthetic • Broken bones, non-respiratory burns, kidney stones• 50/50 concentration with oxygen• Contraindications – AMS, shock, abd trauma, facial

injuries, COPD, head injury

Other pain relief medications

• Some other pain meds you may also eventually come across in EMS– Etomidate – sedative used for pre-hospital drug-

assisted intubation– Fentanyl – used for pain control• Becoming more popular in EMS

– Codeine, Dilaudid, Demerol– Percocet, OxyContin, Hydrocodone– Pain patches (Norco)

Benzodiazapines/Sedatives

• Versed (midazolam) used in Silver Cross EMS system for drug-assisted intubation, seizure control and chemical restraint.

• But medical control may also order Versed as muscle relaxant in long bones fractures, or to reduce anxiety in patient with pain.

• Versed given to reduce pain of cardioversion and pacing, as well as to induce amnesia.

Let’s take 10

• I’ve dug up some old cheesy anti-injury movies from the 1950’s.

• Take a break, grab a pop, watch a bit, and we’ll reconvene in 10 minutes.

• The audio will come from your computer, not your phone.

Some specific examples

• Let’s take a look at some specific examples of calls involving pain, and what steps we can take to reduce that pain to ZERO.

Chest Pain

• Initial treatment does include aspirin– But not for pain, for better cardiac outcome

• ZERO pain comes from:– Nitro – vasodilates, reduces workload of heart

• If initial nitro doesn’t reduce pain, repeat x2 in 5 minute increments if BP > 110 systolic and IV established

• If no IV, contact medical control before giving second dose

– Morphine – reduces muscle pain, reduces stress, reduces workload of heart (reduces preload)

Isolated Extremity Injury

• First control bleeding with direct pressure and elevation.

• Splint fractures, sprains and strains• BLS – a cold pack can reduce swelling and pain• ALS – nitrous oxide can help with fractures– If patient is able to self-administer w/injuries

• ALS – morphine, 5-10mg slow IVP in 5mg increments every five min as needed for pain.– No morphine if hypotension from blood loss.

Crush Injury

• Control pain with morphine, 2mg increments IV/IM as needed for pain.– Call medical control first if patient has respiratory

depression, bradycardia, hypotension

Burns• Cooling/flushing smaller (<20% BSA) thermal

or chemical burns with water can reduce pain.• Water usually not necessary for electrical burns.• Do not put ice or cold packs directly on burns.

• Don’t pour water over entire body• Reduces pain for a while, then causes hypothermia

Burns

• Morphine 5-10mg IVP in 5mg increments every 5 min as needed for pain (no IM).

• Don’t give if pt is in shock (hypotension).

• Nitrous oxide is also an option for burns.

Pediatric Burns

• Remember, kids deserve ZERO pain too!• Cool smaller burned areas with water or

saline.• Kids can get morphine.– 0.1mg/kg (max of 5mg per dose)– Or use length-based pediatric tape (Broslow)– Newborns and young babies don’t get morphine– Call medical control first before giving MS to kids

• Consider nitrous oxide if they can self-administer

Frostbite

• Frostbite victims can get nitrous oxide or morphine to reduce severe pain.– Morphine 5-10mg slow IVP in 5mg increments

every 5 minutes as needed for pain.– Pediatric frostbite – 0.1mg/kg IV/IM, max 5mg per

dose)

• But contact medical control first in this case.

Hazardous Material in Eye

• Flush each eye with 1000ml NS minimum.• Reduces pain and removes harmful

substances• Instill Tetracaine HC 0.5% 1-2 drops to eye for

local anesthesia– Repeat as needed for pain– Remind patient not to rub eyes, since lack of pain

may cause patient to harm eye with rubbing.

Chronic Painwww.webmd.com

• Defined as pain that lasts longer than six months.

• Can be mild or excruciating, episodic or continuous, inconvenient or incapacitating.

• May originate with an initial trauma/injury or infection, or an ongoing medical cause.

• Or can have no cause at all– No past injury or illness

Patients With Chronic Pain

• Higher rates of depression and anxiety.• Sleep disturbance and insomnia common.• Substance abuse highly prevalent in chronic

pain population.– Drug-seeking behaviors

• Chronic pain may contribute to decreased physical activity.– Fear of making pain worse.

The Patient With Chronic Pain

Common Causes of Chronic Pain

• Arthritis• Back Pain• Cancer• Chronic Fatigue Syndrome • Clinical depression • Fibromyalgia • Headache • Irritable Bowel Syndrome • Sciatica • Lumbar spinal stenosis and cervical spinal stenosis

Chronic Pain Treatmentsfrom National Institute of Neurological Disorders and Stroke

• Medications• Acupuncture• Local electrical stimulation• Surgery• Placebos• Psychotherapy• Relaxation• Biofeedback

Chronic Pain and EMS

• Patients with chronic pain call EMS for many reasons– Pain recently got worse– Pain recently changed or moved– Pain now accompanied by new swelling, heat or

deformity– Patient hopes EMS can provide pain medications

that MD cannot

EMS Treatment of Chronic Pain

• The EMS provider should remember that chronic pain is still a medical disorder– Not all in their head– Not all patients with chronic pain are drug-seekers– Not all patients with chronic pain are “whiners”

• Do not make light of their condition• But do contact medical control with your

concerns before providing ALS pain relief

In Summary

• EMS goal in most cases is ZERO pain.• Don’t be afraid to use the tools we have to achieve

that goal.• Our SMO’s allow us to use many treatments for pain.

But always contact medical control with questions or concerns.

Speaking of SMO’s…

• Region 7 will be rewriting and updating the ALS SMO’s in the coming months.

• If you have valid concerns and can support a claim for change, the committee will consider it.

• Email Lonnie at lpolhemus@silvercross.org with requests for SMO changes.

Questions?

• Questions? Please type them into dialogue box to the right of this screen (if viewing live)

• Please call 815-740-7130 or email afinkel@silvercross.org if you think of questions later.