Pain Management

Table of Contents

(Incorporates elements of an evidence-based guideline for prehospital analgesia in trauma created using the National Prehospital Evidence-Based Guideline Model Process)

Aliases

Analgesia, pain control, acute pain, acute traumatic pain, acute atraumatic pain

Patient Care Goals

The practice of prehospital emergency medicine requires expertise in a wide variety of pharmacological and non-pharmacological techniques to treat acute pain resulting from myriad injuries and illnesses. Approaches to pain relief must be designed to be safe and effective in the dynamic prehospital environment. The degree of pain and the hemodynamic status of the patient will determine the urgency and extent of analgesic interventions.

Patient Presentation

Inclusion Criteria

Patients who are experiencing pain

 Exclusion Criteria  

  1. Excluded from Opioids Only
    1. Pregnancy with active labor
    2. Dental pain
    3. Patients with care-plans that prohibit use of parenteral analgesics by EMS
    4. Patients with chronic pain who aren’t part of a hospice/palliative care plan

Patient Management

Assessment, Treatment, and Interventions

  1. Determine patient’s pain score assessment using standard pain scale.
    1. Less than 4 yo: Observational scale (e.g. Faces, Legs, Arms, Cry, Consolablity [FLACC] or Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)
    2. 4-12 yo: Self-report scale (e.g. Wong Baker Faces, Faces Pain Scale [FPS], Faces Pain Scale Revised [FPS-R])
    3. Greater than 12 yo: Self-report scale (Numeric Rating Scale [NRS])
  2. Place patient on cardiac monitor per patient assessment
  3. If available, consider use of non-pharmaceutical pain management techniques
    1. Placement of the patient in a position of comfort
    2. Application of ice packs and/or splints for pain secondary to trauma
    3. Verbal reassurance to control anxiety
  4. If not improved and patient is experiencing discomfort or pain, consider use of analgesics as available
    1. For mild, moderate, or severe pain: Acetaminophen 15 mg/kg PO (maximum dose 1 g)
    2. For moderate to severe pain: Fentanyl 1 mcg/kg IN/IM/IV/IO (maximum initial dose of 100 mcg)
      1. IM or IN is preferred for the first dose
      2. Patient must have Systolic Blood Pressure above 90 mmHg or age-appropriate Systolic Blood Pressure.
  5. Establish IV per patient assessment
  6. For sedation prior to painful field procedures (Entrapped patient extrication, manipulation of known fracture/dislocation, removal of burned clothing adhered to skin, etc)
    1. To be used when fentanyl has failed or is expected to fail analgesia attempts. 
    2. EMS Physician consulting is strongly recommended via medical direction phone prior to medication administration
    3. Ketamine
      1. 1 mg/kg IV/IO, max of 250 mg
      2. 4 mg/kg IM, max of 500 mg
    4. Requires continuous cardiopulmonary and waveform capnography monitoring
    5. Document RASS similar to agitated patients (Pre and Post Sedation)
  7. If indicated based on pain assessment, and vital signs allow, repeat pain medication administration after 5 minutes of the previous dose
    1. For mild, moderate, or severe pain: Administer Acetaminophen if not already given
    2. For moderate to severe pain: Fentanyl 0.5 mcg/kg IV/IO/IN/IM, max of 50 mcg per dose.
      1. Patient must have Systolic Blood Pressure above 90 mmHg or age-appropriate Systolic Blood Pressure and Respiratory Rate > 10/min
  8. Consider administration of oral, sublingual, or IV antiemetics to prevent nausea in high risk patients [see Nausea/Vomiting guideline]
  9. Transport in position of comfort and reassess as indicated

Notes – Pain Management