Notes – Pain Management

Pain Management

Patient Safety Considerations

1. All patients should have drug allergies identified prior to administration of pain medication
2. Administer opioids with caution to patients with GCS less than 15, hypotension, identified medication allergy, hypoxia (oxygen saturation less than 90%) after maximal supplemental oxygen therapy, or signs of hypoventilation
3. Use of splinting techniques and application of ice should be done to reduce the total amount of medication used to keep the patient comfortable

Notes/Educational Pearls

Key Considerations

1. Pain severity (0 – 10) should be recorded before and after analgesic medication administration and upon arrival at destination
2. Patients with acute abdominal pain should receive analgesic interventions – Use of analgesics for acute abdominal pain does not mask clinical findings or delay diagnosis
3. Opiates may cause a rise in intracranial pressure

Pertinent Assessment Findings

1. Mental status (GCS and pain level)
2. Respiratory system (tidal volume, chest rigidity)
3. Gastrointestinal (assess for tenderness, rebound, guarding, and nausea)

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

• 9914071 – General-Pain Control

Key Documentation Elements

• Documentation of patient vital signs with pulse oximetry
• Acquisition of patient’s allergies prior to administration of medication
• Documentation of initial patient pain scale assessment
• Documentation of medication administration with correct dose
• Documentation of patient reassessment with repeat vital signs and patient pain scale assessment

Performance Measures

• The clinical efficacy of prehospital analgesia in terms of adequacy of dosing parameters
• EMS Compass® Measures (for additional information, see http://www.emscompass.org)
  • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
  • Trauma-01: Pain assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
  • Trauma-02: Pain re-assessment of injured patients. Recognizing that pain is under-treated in injured patients, it is important to assess if a patient is experiencing pain

Universal Pain Assessment Tool

Faces, Legs, Activity, Cry, Consolablity (FLACC) Behavioral Scale

Appropriate age for use (per guideline): less than 4 years

Instructions:

• Patients who are awake: Observe for at least 1-2 minutes. Observe legs and body uncovered. Reposition patient or observe activity, assess body for tenseness and tone. Initiate consoling interventions if needed
• Patients who are asleep: Observe for at least 2 minutes or longer. Observe body and legs uncovered. If possible reposition the patient. Touch the body and assess for tenseness and tone.
• Face
  • Score 0 point if patient has a relaxed face, eye contact and interest in surroundings
  • Score 1 point if patient has a worried look to face, with eyebrows lowered, eyes partially closed, cheeks raised, mouth pursed
  • Score 2 points if patient has deep furrows in the forehead, with closed eyes, open mouth and deep lines around nose/lips
• Legs
  • Score 0 points if patient has usual tone and motion to limbs (legs and arms)
  • Score 1 point if patient has increase tone, rigidity, tense, intermittent flexion/extension of limbs
  • Score 2 points if patient has hyper tonicity, legs pulled tight, exaggerated flexion/extension of limbs, tremors
• Activity
  • Score 0 points if patient moves easily and freely, normal activity/restrictions
  • Score 1 point if patient shifts positions, hesitant to move, guarding, tense torso, pressure on body part
  • Score 2 points if patient is in fixed position, rocking, side-to-side head movement, rubbing body part
• Cry
  • Score 0 points if patient has no cry/moan awake or asleep
  • Score 1 point if patient has occasional moans, cries, whimpers, sighs
  • Score 2 points if patient has frequent/continuous moans, cries, grunts
• Consolablity
  • Score 0 points if patient is calm and does not require consoling
  • Score 1 point if patient responds to comfort by touch or talk in ½ – 1 minute
  • Score 2 points if patient require constant consoling or is unconsoled after an extended time

Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report.

When self-report is not possible, interpretation of pain behaviors and decision-making regarding treatment of pain requires careful consideration of the context in which the pain behaviors were observed.

Each category is scored on a 0-2 scale, which results in a total score of 0-10

Assessment of Behavioral Score:

• 0 = Relaxed and comfortable
• 1-3 = Mild discomfort
• 4-6 = Moderate pain
• 7-10 = Severe discomfort/pain

© 2002, The Regents of the University of Michigan. All Rights Reserved.

Source: The FLACC: A behavioral scale for scoring postoperative pain in young children, by S Merkel and others, 1997, Pediatr Nurse 23(3), p. 293–297.

References

1. Attard AR, Corlett MJ, Kidner NJ, Leslie AP, Fraser IA. Safety of early pain relief for acute abdominal pain. BMJ. 1992;305(6853):554-6.
2. Bieri D, Reeve R, Champion GD, Addico at L, Ziegler J. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: Development, initial validation and preliminary investigation for ratio scale properties. Pain 1990;41:139-150.
3. Brewster GS, Herbert ME. Hoffman JR. Medical myth: analgesia should not be given to patients with acute abdominal pain because it obscures the diagnosis. West J Med. 2000;172(3):209-10.
4. Prehospital use of Ketamine in Battlefield Analgesia 2012-13. Falls Church, VA: Defense Health Agency; March 8, 2012. Correspondence to Assistant Secretary of Defense (Health Affairs).
5. De Nadal M, Munar F, Poca MA, Sahuquillo J, Garnacho A, Rosselló J. Cerebral hemodynamic effects of morphine and fentanyl in patients with severe head injury: absence of correlation to cerebral autoregulation. Anesthesia. 2000;92:1-11.
6. Hicks CL, von Baeyer CL, Spafford P, van Korlaar I, Goodenough B. The Faces Pain Scale – Revised: Toward a common metric in pediatric pain measurement. Pain. 2001;93:173-83.
7. Jennings PA, Cameron P, Bernard S. Ketamine as an analgesic in the pre-hospital setting: a systematic review. Acta Anaesthsiol Scand. 2011;55(6):638-43.
8. LoVecchio F, Oster N, Sturmann K, Nelson LS, Flashner S, Finger R. The use of analgesics in patients with acute abdominal pain. J Emerg Med. 1997;15(6):775-9
9. Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2007 Jul 18;(3)CD005660.
10. Merkel S, e al. The FLACC: A behavioral scale for scoring postoperative pain in young children., Pediatr Nurse. 1997;23(3):293–7.
11. Odhner M, Wegman D, Freeland N, Ingersoll G. Evaluation of a newly developed non-verbal pain scale (NVPS) for assessment of pain in sedated critically ill patients. Available at: http://www.aacn.org /AACN/NTIPoster.nsf/vwdoc/2004NTI Posters. Accessed July 18, 2017.
12. Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996;3(12):1086-92.
13. Porter K. Ketamine in prehospital care. Emerg Med J 2004;21:351-4.
14. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296(14):1764-74.
15. Svenson JE, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007;25:977-80.
16. Vermuelen B, Morabia A, Unger PF, et al. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate – a randomized trial. Radiology. 1999;210(3):639-43.
17. Wiel E, Zitouni D, Assez N, et al. Continuous infusion of ketamine for out-of-hospital isolated orthopedic injuries secondary to trauma: a randomized controlled trial. Prehosp Emerg Care. 2015;19(1);10-16.
18. Wood PR. Ketamine: prehospital and in-hospital use. Trauma. 2003;5(2):137-40.