Pain Management

Objectives

Case Studies/Discussion

Fentanyl

Dilaudid

KetamineSub dissociative dosing for pain management.

Synergistic Effects

Focus on developing a plan for every call.

Add www.rffe.org to the home screen of your phone.

Case #1 Aspen Ambulance

Called to a 34 year old female CC Shoulder injury on the sidewalk by the base of the Gondola.

Pt AAOX4 M&SX4

9/10 pain in left shoulder

Obvious deformity

Pt unable to move due to pain.

HR: 116 BP: 140/ 90 RR: 24

SpO2: 96%

Pt weights 100Kg

Your plan is to administer Fentanyl for

pain while on scene.

What is your initial dose?

How long until onset?

How long will it last?

What are your concerns?

What is your treatment plan?

After 5 minutes the patients pain goes

down to 5/10 and she is complaining of

spasming in his arm.

Is his pain Managed?

How long before you can administer more?

What will your second dose be?

You decide to use Versed along with your

second dose.

How much do you draw up?

What do you expect now?

Goals of pain management

Make the patient comfortable

Continually monitor your patient!

What are you looking for?

Precautions of Pain Management

Constantly reassess and monitor your

patients for respiratory depression.

Have a backup plan for airway management.

Give meds Slow IVP

Your patient is nauseous. What are your

options?

Case # 2 Ski Patrol

You are called to a 40 year old male Skier

vs. rock. CC: Right lower leg pain and

deformity. Pain 7/10 (appears to be tib/fib)

Pt located in the Highland bowl mid slope

AAOX4

Found laying next to a rock with obvious boot

top deformity.

HR: 120 BP:146/90 RR: 20 SpO2: 94%

Weight: 80kg

You decide to use Dilaudid to manage his

pain.

What is your initial dose?

How do you administer Dilaudid?

How long before it starts to help?

How long do you expect it will last?

You administer first dose prior to

packaging the patient which takes approx

15 minutes

Patient is placed on a scoop for transport

As you move down the bowl the patient tells you he is in 6/10 pain and thinks he is going to throw up.

Its been almost 20 minutes since the first dose.

Do you give more Dilaudid? How do you continue to manage his pain?

How much?

Ketamine

How should you use Ketamine with the last

2 patients?

Less opiate/narcotic use

Patients often less anxious and more

comfortable

Lowered risk of nausea/vomiting

Quicker onset than Dilaudid, same as Fentantyl

Almost no concern for respiratory depression

Ketamine Protocol

Administration and Dosage:

Analgesia

0.3mg/kg (IV or IO), Titrate to effect

0.5mg/kg (IM)

Time to effect is 45-60 seconds

Duration of action is 10-20 minutes

Round dosage down to nearest 5mg increment

Basalt Ambulance

27 year old male bike accident in the park

80 Kg patient

CC: Rib pain 9/10

AAOX4 -LOC

HR: 110 RR: 20 shallow SpO2: 90%

Your plan is to administer Narcotic pain

management and Ketamine as an adjunct.

Narcotic options and doses?

Fentanyl

Dilaudid

You choose 1mg Dilaudid.

Pts pain goes down to 7/10 but soon rises to

8/10 eight minutes post administration

How much Ketamine to you want to give?

20mg Ketamine SIVP administered en

route.

Patients pain decreases to 1/10 two minutes

post administration.

Pts pain remains 1/10 for entire transport to

AVH.

Pts SpO2 increases to 98%

Respirations become less labored and more

effective. By arrival at AVH, pt able to take

deep breaths and is virtually pain free.

Snowmass Patrol/Snowmass

Ambulance

55 year old male skied off side of terrain

park jump. CC: Bilateral femur fx.

Pain 10/10 in both legs 80 Kg patient

Pt AAOX4 -LOC

HR:126 BP: 150/86 RR: 28 SpO2: 90%

Your plan is to administer Narcotics and

Benzos because that’s what you have on

you

What do you want to give and how much?

On scene EMTs package your pt and you

draw up your meds.

200mcg Fentanyl (100mcg given twice)

1mg Versed

Pts pain remains 10/10

Pt is now ready for transport but screams

in pain at the slightest movement.

Option 1:

Give more Opiates and BenzosThoughts/Concerns?

Benefits?

Option 2:

Call for another medic to bring you Ketamine?Thoughts/Concerns?

Benefits?

Ketamine arrives and you administer

20mg SIVP.

Within one minute pt is no longer in pain.

Pt remains pain free for entire 15 minute

toboggan ride.

Upon arrival you tell ambulance medic that

last Fentanyl dose was 25 minutes prior

and Ketamine was 15 minutes prior.

Does the ambulance medic need to

administer more of each?

Snowmass Ambulance administers

20 mg Ketamine

1 mg Dilaudid

4 mg Zofran

Pts HR decreases to 90

Respirations remain adequate and

effective.

Pt remains AAOX4 and completely

unaware that his legs are broken.

Patient handoff that the pt received:

200mcg Fentantyl

1mg Versed

1mg Dilaudid

50mg Ketamine

4mg Zofran

Begin your Pt handoff to the nurses with the

most recent tx, then give the entire list.

The Take Away

Don’t under dose or not dose your patients!

Make them comfortable.

Consider Ketamine when using narcotics.

Allows for more effective pain management

Lower dose of Narcotics

A better experience for your patient

More documented uses of Ketamine will

allow us to provide positive data to the

state and keep it in our protocols.

Don’t be afraid to use Ketamine as an

adjunct to analgesia.

If you haven’t used it yet, consider it next time

you have a patient in true pain.

Mention it to your partner on your next call if

they don’t think about it.

It was put in our protocols because it

works, our docs want us to use it and our

patients have better/quicker recoveries!

Data Collection:

Fill out form on www.rffe.org