PrehospitalPain Management
Protocols and Ideas
Michael W. Dailey, MD FACEP
Regional EMS Medical Director
Associate Professor
of Emergency Medicine
Albert Schweitzer - 1931
“We all must die. But that I can save him from days of
torture, that is what I feel as my great and ever new
privilege. Pain is a more terrible lord of mankind than
even death itself.”
Disclosure
No academic conflict of interest
No financial conflict of interest
FDA Off-label use of a medication will be discussed
Have you ever been trapped in a small box with someone who is Crying? Screaming? Sobbing?
Objectives
Pain management is a central focus in hospital
based-medical care.
Currently, time to pain management is also an
important metric for the in-hospital management of
patients with long-bone fractures.
If a patient has received pain management from EMS,
it not only provides improved care, but also assists in
the ED management of the patient.
Federation of State Medical Boards Model Policy—2004
Policy states the under-treatment of pain is a
departure from an acceptable standard of practice
Inappropriate pain treatment includes:
– Nontreatment
– Undertreatment
– Overtreatment
– Continued use of ineffective treatments
JCAHO Pain Standards
Patients have the right to appropriate assessment and
management of pain
Institutions must respect and support patients’ rights
to pain management
Patients have a right to expect that their pain reports
will be believed and to receive a quick response
NAEMSP Position Paper
Mandatory pain assessment
Indications for pain management
Alternatives for pain management
Patient monitoring
Transfer of patient information
Quality improvement and medical oversight
Research
Began with cancer pain
Extended to all acute and chronic pain syndromes
Track record is appalling
Review of >7000 articles
“most” of 23 million post op patients inadequately
treated for pain
Specific groups at greater risk
Literature
Hundreds of studies
Women
Children
Elderly
Non-white
Co-morbid disease
History of pain
Bottom line: There has never
been a study that indicated
medical providers did an
adequate job of managing pain!
NEVER!
Why Is Pain Undertreated?
Fear of regulatory oversight (leading cause)
Lack of medical training
Misunderstandings about addiction
Inadequate reimbursement mechanisms
Lack of routine assessment
Misunderstanding about adverse events
http://www.deadiversion.usdoj.gov/pubs/nwslttr/spec2001/page10.htm
Paramedic Attitudes
Objective signs
Potential malingering
Ambivilence about the degree of pain control to target
Fear of masking symptoms
Aversion to aggressive dosing
16
Walsh, et al, PEC Vol 17, No 1, Jan-Mar 2013, 78-88
Pain Management in the ED and in EMS
So, What Can You Do?
Learn a range of responses
– Analgesia does not equal conscious sedation
Tailor therapy to patient pain
Be prepared to adjust therapy
Use adjuncts
Work together - discuss plan for analgesia
Start with the easy stuff
Splinting / positioning / reduction*
Ice
IN or IM or IV opioid
In the ED:
Hematoma block
Regional block
Don’t cause more pain before relieving baseline
Parenteral Pain Management
Morphine
Fentanyl
Dilaudid
Demerol
Toradol
Ketamine
Give early
Give enough
Give often enough
What else is done around the country?
Study Objectives
Most Emergency Medical Systems (EMS) have
developed protocols that allow EMS personnel to
administer analgesic medications without prior contact
with a physician.
The prevalence and scope of prehospital analgesia
protocols nationwide is unknown, as is the trend in
practice.
The objective was to assess current prehospital
analgesia practices.
Dailey, Tran and Goldfine, 2014
Methods
An online survey focusing on analgesia protocols and
agents was sent to 50 EMS Directors and Medical
Directors.
Follow up telephone calls were made to assure 100%
compliance.
Data is analyzed with descriptive statistics and
compared to a survey from 2007 that also had 100%
compliance.
Results:
We had 100% survey compliance after email
participation and follow up telephone contact. There is
great variation around the country in the way that
protocols are written and approved.
In 29 states analgesia protocols are statewide, but
there may still be regional or service variation.
Sample 1
If pain management is needed, consider:
a.) Fentanyl 1-2 mcg/kg IV or IM up to 100 mcg initial
dose. Contact physician for orders past 200 mcg
total.
b.) Morphine 4 mg IV initial dose titrated to
pain/pressure. Contact base physician for orders past
20 mg total.
c.) Versed 2 mg IV or IM initial dose, may give
another 2 mg after five minutes if needed.
Sample 2
Consider the use of fentanyl 25-50 mcg IVP every ten
minutes titrated to effect with maximum dose of 200
mcg as long as vital signs are stable.
Consider self-administered fixed dose of 50% nitrous
oxide/oxygen mixture delivered by commercially
available device such as Nitronox.
Sample 3
EMT-Intermediate may administer analgesic for pain:
morphine 2-5 mg IV or IM, repeat every five minutes
as needed to a maximum of 15 mg (as long as vital
signs are stable).
Paramedic may administer alternative analgesic of
choice if SBP > 100 mmHg. (Includes ketorolac,
fentanyl, morphine)
A chest pain protocol...
Nitroglycerin 0.4 mg SL.
Medical Control may authorize additional nitroglycerin
administrations if pain is still unrelieved.
Administer morphine sulfate 2 mg over two minutes IV.
Do not repeat, as additional doses may mask the acute
MI.
30
Let’s look at some specific medications
Fentanyl
Analgesia and euphoria
Rapid onset
Short duration (20 minutes)
Reversible
Respiratory depression
Fentanyl
IN (not FDA approved)
– Dose 1.5-2.5 mcg/kg*
– Maximal effect 3-5 minutes
– Advantages?
IM
– Dose 1-1.5 mcg/kg
– Maximal effect 5-10 minutes
IV
– Dose 0.5 - 1 mcg/kg
– Maximal effect 3-5
minutes
Results - Fentanyl
The use of fentanyl by EMS providers has increased
to 92% of states (n= 46) from 48% (n=24).
Fentanyl - 2007
Fentanyl - 2013
Ketamine
IN* or IM or IV
Fast onset
Maintains airway
reflexes
Dissociative and sub-
dissociative dosing
Emergence reactions
Why Ketamine?
Airway reflex sparing
Supports BP / HR
Additive to opioid
Reduces need for additional opioid
– Dosing 0.1 – 0.2 mg/kg (10 – 20 mg)
– Most patients given low dose ketamine need less morphine
Jennings PA, Cameron P, Bernard S, et al. Morphine and
ketamine is superior to morphine alone for out-of-hospital trauma
analgesia: A randomized controlled trial. Ann Emerg Med, Jan 11,
2012 [e-pub ahead of print].
Ketamine Dosing
IN pain management (not FDA approved)
– 0.5 mg/kg or 50 mg intermittent dosing
IM sedation for acute agitation
– 3-5 mg/kg
IM for pain management
– 0.5 mg/kg
IV for pain management
– 10 to 20 mg over 10 minutes
Results - Ketamine
Ketamine also has a growing use in EMS as well,
with an increase from 6 states to 16.
Indications were not reveiwed in the study
– Some for induction
– Some for disentanglement
– Some for adjunctive pain management
Ketamine - 2007
Ketamine - 2013
Results: Standing Orders
98% of the states allow the administration of opioid
analgesia without contact with a physician, an
increase from a 2007 study 78% (n=39).
Analgesia - 2007
Standing Order Analgesia - 2013
National EMS Practice
Prehospital standing order analgesia is a well-
validated clinical practice is the national standard of
care.
All states with the exception of South Carolina allow
administration of analgesics to patients in pain without
prior contact with a physician.
There is a growing trend to the use of ketamine in
EMS practice.
Fentanyl is the opioid analgesic agent of choice for
EMS.
What else is there?
Non-steroidals
Inhaled agents
Benzodiazepines
Acetaminophen
Ketorolac
Non-steroidal anti-inflammatory
Toxic in renal insufficiency
Effective for musculo-skeletal injuries and renal
stones
Requires physician order in Collaborative Protocols
Midazolam
Not an analgesic
Additive to opioid
Reduces spasm
Amnesia at higher doses
Unpredictable dosing
Requires physician order
Inhaled agents
Methoxy-fluourane
– Patient administer analgesia
– Very effective for minor pain
– Not available in US
Nitrous oxide
– Available for advanced EMT agencies only
– Patient administered
– May reduce need for opioids
Acetaminophen
Now available IV
Reduces need for opioids for post-op pain
Restricted because of cost at AMC
Offers an oral option in the ED or some EMS
agencies
But what about…diversion?
What about Diversion?
Diversion is real
Consider the potential with every medication added
Use engineering controls and procedure to attempt to
control
Realize it might happen
“How could this happen to us?”
MedPage Today Accessed 11/10/2014
What about “Prescription Monitoring”?
Legislation designed for the control of overprescribing
of opioids
Designed to catch bad doctors, bad pharmacists and
bad patients
Does not apply to acute care of patients in severe
pain
What is Optimal EMS Pain Management?
A wide range of options for different situations
– Opioids on standing orders
– Benzodiazepines for spasm +/- standing order
– NSAIDs for renal colic +/- standing order
– Ketamine for disentanglement and maybe adjunctively
Oversight and safety for the patients
– Must be close review of usage
Oversight and safety for the providers
– Must be clear compliance with regulatory requirements
Conclusions
Develop a range of responses
Tailor the therapy for the anticipated procedure
Patient report of pain and subjective complaint drives
your care
Treat early and often, it requires less overall
If you have any questions, talk about it
Golden rule of pain management …
Pain is whatever the patient says it is…
Thank you.
Top Related