Transcript 2014 May Basic Assessment and Management of Pain for the BLS

Assessment and Management
of Pain for the BLS Provider
Presence Regional EMS
May 2014 Continuing Education
Objectives
 Recognize the importance of pain assessment and management
in the Pre-Hospital setting.
 Discuss some common misconceptions held by EMS providers
regarding pain.
 Demonstrate the use of patient self reporting of pain using a 010 scale and other adapted scales
 Show how the use of OPQRST can help the patient in pain
further define what they are feeling.
 List effective non pharmacological techniques EMS providers
can use to help a patient manage pain.
 Review effective pharmacological management EMS providers
can use to help a patient manage pain.
12 Painful Myths: Read each
statement and decide if it is
TRUE or FALSE
1. Patients with a history of substance
abuse do NOT have a right to effective
pain management.
2. Infants and small children have such
poorly developed nervous systems
that they rarely feel severe pain.
3. Sedation or sleeping is an indicator of
pain relief.
4. Pain is what the patient says it is.
5. The EMS provider’s personal values and
intuition about the trustworthiness of the
patient is a valid tool in identifying if the
patient is lying about pain.
6. Comparable physical stimuli produce
comparable pain in all people.
7. The more prolonged the pain or the more
experience a person has with pain, the better
the tolerance of pain.
8. Patients expect to have their pain relieved.
9. Lying about the existence of pain is very
common.
10. Pain is largely an emotional or psychological
problem, especially in a patient who is highly
anxious or depressed or who has an unclear physical
cause for pain.
11. All real pain has an identifiable physical cause.
12. Visible signs, either physical or behavioral,
accompany pain and can be used to verify its
existence and severity.
What is pain?
Pain is defined as an unpleasant
(not fun) sensory (response of the nervous system)
and emotional (colored by a variety of emotions,
fear, anger, despair) experience that is
associated with actual (real) or
potential (in the process like ischemia) tissue
damage.
Pain is Subjective
 The pain belongs to the patient.
 The patient with the pain is the only authority
about the pain
 The sensation of pain is felt only by the
patient.
 Past experiences and beliefs color perception
of pain.
Past Experience
 Past experiences that color the perception of
pain may be pain that the patient has had
before or experiences in dealing with the pain
in the past
 Patient will report pain based on how it
compares to the pain they have had in the
past
As a Professional
 Accept and appreciate that only the
patient can feel pain.
 Measure the pain by asking repeatedly
Adaptation
 Adaptation occurs when a patient is
experiencing reoccurring or chronic
pain. The patient has “gotten used to”
the pain. While the pain is still present,
the patient will present with normal
vital signs and may even appear to be
free of pain.
Adaptation: Patients who have adapted will
appear different than those with a new
experience of pain
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Acute Pain - New Pain
↑ Blood Pressure
↑ Pulse
↑ Respirations
Dilated pupils
Diaphoretic
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Adaptation - Chronic Pain
Normal blood pressure
Normal pulse
Normal respirations
Normal pupils
Dry
Acute Pain
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Focuses on pain
Cries and moans
Rubs painful part
Muscle tension
Frowns/grimaces
Adaptation
Does not report
Tries to sleep
Distracts self
Physically inactive
Blank or normal
facial expression
Contributing Factors
 There are factors that contribute to how the patient
perceives or reports pain. A wide variety of factors
can play into how pain is reported to the EMS
provider.
Contributing Factors
 Cultural expectations: Some cultures expect
patients to complain loudly and dramatically about
pain, while some cultures expect individuals to be
very stoic and never complain of pain.
 Recognize the patient’s culture and
accept their response to pain accordingly.
 What is this sensation called again? Particularly
with cardiac pain, some patients perceive the
sensation not as pain but as pressure or burning.
Ask the patient what the
sensation is like and refer to
the sensation using these
words.
 Past experience with pain: A man who had
bilateral femur fractures when he was 16 years old,
has some experience with pain so at the age of 60 he
may report cardiac chest pain at a lower numerical
number. On the other hand, 60 year old man with
chest pain who has never experienced much pain in
the past, but whose father died of a heart attack at
age 60 may report the pain at a very high number.
 “I don’t want to be a bother” Some patients
don’t want to draw attention to themselves or want
to make more work for EMS providers , so they will
down play their pain.
What if they are faking it?
 Research shows that very few patient lie
about having pain that they don’t have.
 More often patients will down play pain
or tell EMS providers they don’t have
pain or insist that they have very little
pain at all
Can you tell by looking at someone
who is in pain and who is not?
 How reliable are your values, beliefs and
prejudices?
Is there a source for this feeling?
 All pain has both physical and
psychological components.
 The absence of an identifiable physical
cause does not mean the pain does not
exist
What is with emotions and pain?
 Anxiety is associated with new onset, brief
pain
 Depression is associated with prolonged
pain
Individual Responses to Pain
 What are the cultural expectations for pain? Do they
tell you about pain or hold it in?
 What are the learned expectations? If a patient with
chronic pain has not had pain relived in the past, they
will not expect to get any help or support from EMS
Providers
Non-Verbal Behaviors
 A patient’s non-verbal behaviors can be a
blessing or a curse. Patients with chronic pain
have adapted to be able to position
themselves comfortably in spite of the pain.
Nonverbal Behaviors
 Not all patients that are in pain will exhibit
signs.
 With chronic pain, patients may have adapted
to be able to better live their lives with pain.
 Acute pain may or may not cause a physical
reaction such as guarding the affected area.
 Nonverbal behaviors may not reflect patients
level of pain.
Nonverbal Behaviors
 Visible signs unreliable due to adaptation
Can you tell who
is in pain?
Physical Assessment of Pain
 Palpation is commonly used to assess tenderness.
 Useful in children, patients with altered mental
states, developmentally disabled, and patients
who speak foreign languages.
 May note patient to be guarding area of pain or
withdrawing when EMS attempts to assess.
 Area of pain may be tender when palpated.
 May also notice DCAPP-BTLS in area of origin of
pain.
Verbal Assessment of Pain
 O – Onset
 P – Palliative/Provocation
 Q – Quality
 R – Region/Radiation
 S – Severity
 T – Time
How is pain measured?
 Can use 0-10 scale individually or as part of your
OPQRST
 Can use visual aids to measure pain.
Onset
 Can be used to determine what the
patient was doing at time the pain
began.
 Helpful in determining what caused the
pain.
 Can be assessed by asking ‘What were
you doing when the pain began? Did
anything cause your pain?’
Palliative and Provocation
 Used to determine if pain is made worse
or better with anything the patient or
EMS providers do in attempt to relieve
it.
 Ask ‘Does anything make the pain
worse?’ and ‘Does anything make the
pain better’ separately to avoid
confusion.
Quality
 A descriptor is order to determine what
the patient is feeling.
 ‘What is the pain like?’
 Can use helpful terms such as: sharp,
dull, crushing, tearing, pressure,
throbbing, etc.
Region/Radiation
 Determine the location of the pain.
 Determine if the pain is localized or if it
presents in other locations as well.
 ‘Where does it hurt?’
 ‘Does the pain move anywhere’
Severity
 Use to measure the patients pain.
 0-10 scale
 0 is no pain and 10 is intolerable pain
 One measurement is baseline
 Frequent measurements are needed
Time
 Determine how long this episode has been
going on.
 Can also determine if patient has had this type
of pain before and if the pain is constant or
not.
 ‘How long have you had this pain?’
 ‘Has the pain been constant or does it come
and go?’
 ‘Is this the first time you have felt pain like
this before?’
Pain Tolerance
 The amount of pain a person is willing to
endure.
 Tolerance is a unique response not
everyone is the same.
 Prolonged or recurring pain with no
assurance of relief lowers tolerance.
 Make an agreement for pain control.
 The patient can give a number 0-10 of how
much pain they can tolerate.
Techniques to Treat Pain
 Reassure the patient. Let the patient know
that their pain is a priority for you and that
they are receiving the help they asked for.
 Position patient in a position of comfort on
the cot. Pad the cot around the patient if
necessary.
 Use heat and cold packs as appropriate to
ease pain.
 Call for ALS to manage severe pain.
Pharmaceuticals Available to ALS
Providers
 Upon ALS arrival give report including
patients complaint, vital signs, medications,
allergies, and medical history.
 ALS providers have ability to administer
Morphine, Demerol, and Fentanyl to control
pain.
 Can also administer Zofran to assist with
nausea often associated with administration
of analgesic medications.
BLS provider and Chest Pain
 Classic area is sub sternal with radiation to left
shoulder, arm, jaw, and back.
 Chest pain can be caused by Acute Coronary
Syndrome.
 Can lead to damage or death of heart tissue
and cardiac arrest.
 Is a serious condition that BLS providers can
start initial treatment for.
 ALS intercept should be requested.
EMT-Basic Treatment of Chest Pain
 Able to administer medications to assist the patient
suffering from chest pain.
 Oxygen administered at 15lpm via NRB to oxygenate
damaged tissue.
 325mg ASA administered as a clot inhibitor.
 Nitroglycerin 0.4 mg given SL up to 3 times for
vasodilation of blood vessels.
 Reassess vital signs between doses of Nitroglycerin.
 KNOW YOUR INDICATIONS AND CONTRAINDICATIONS!
Case Presentation #1
 You are called for a 74 year-old female who
has fallen in middle of the night. Patient is
complaining of right hip pain. Denies any
further complaints.
 Upon arrival you find patient laying in the
bathroom. Patient appears to be in a great
deal of discomfort.
 Scene is safe and family is present.
General Impression
 Patient is laying supine on floor guarding her
right hip.
 Note right leg shorter than left with right foot
rotated outwards.
 Patient is in excruciating pain when hip is
palpated and when she attempts to move it.
Initial Assessment
 Airway: patent
 Breathing: 24 breaths/min
 Circulation: pulse is 120 and BP is 170/100;
slightly pale and sweaty
 Disability: Alert and oriented; unsure of how
long she has been on floor
 Exposure: Tenderness to right hip; shortening
and rotation of right leg. No other trauma.
OPQRST
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Onset: Began after falling due to tripping on a rug
Palliative: Nothing makes the pain better
Provocative: Hurts more when palpate or she moves it
Quality: Sharp pain
Region: Right hip
Radiation: Pain shoots down her right leg
Severity: 7/10
Time: Pain has been constant since it began
Management Priorities
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Consider early need of ALS for pain management.
Consider need for spinal motion restriction devices.
Immobilize leg prior to movement of patient.
Pad around patient and pad the voids between
patient and backboard in attempts to make patients
comfortable.
 Explain procedures to patient and use personnel
appropriately in order to ensure smooth movement
of patient.
Case Summary
 ALS arrives on scene and manages patient’s
pain.
 Patient arrives at ED without incident and is
found to have a femur fracture just distal to
the femoral head.
Case Presentation #2
 You are called to a local business for a 26 year
old female complaining of abdominal pain.
 Upon arrival you are led to a cubical where
you find your patient seated in a chair
vomiting into a waste basket.
 Scene is safe.
General Impression and Physical
Assessment
 Patient is seated in chair vomiting into waste
basket.
 Patient is anxious and guarding the right side
of her abdomen.
 Upon palpation of patients abdomen find
patient to have increased pain when the
lower right quadrant is released.
 No further physical findings.
Initial Assessment
 Airway: patent
 Breathing: 24 breaths/min
 Circulation: pulse is 120 and BP is 110/70;
slightly pale and sweaty
 Disability: Alert and oriented; anxious
 Exposure: Rebound tenderness to right lower
quadrant of abdomen.
OPQRST
 Onset: Pain has been present since she
awoke this morning
 Palliative: Nothing is making the pain better
 Provocative: It hurts slightly worse when
palpated, but much worse when pressure on
it is released
OPQRST
 Quality: Sharp, stabbing pain
 Region: Pain in the lower right quadrant of
her abdomen
 Radiation: None
 Severity: 10/10
 Time: Constant since it began and it keeps
getting worse
Management Priorities
 Consider need for ALS intercept
 Place patient on cot in position of comfort.
 Reassess patient for changes in vital signs and
monitor her pain levels.
 Reassure patient.
Case Summary
 ALS arrives and contacts medical control in
order to assist with pain management and
control of vomiting/nausea.
 Patient arrives at ED and is treated for
appendicitis.
Case Presentation #3
 You are dispatched to a residence for a 58
year-old male patient having chest pain.
 Upon arrival you find patient on the front
porch clutching his chest.
 Scene is safe; you notice lawn is partially
mowed and mower is turned off in the middle
of the yard.
General Impression
 58 year old male patient is sitting on porch
 Patient is very anxious
 Patient appears to be having difficulty
breathing
Initial Assessment
 Airway: patent
 Breathing: 24 breaths/min, lungs are clear
 Circulation: pulse is 130 and BP is 150/90; pale,
cool, and sweaty
 Disability: Alert and oriented; anxious
 Exposure: Patient is clutching his chest with
his right hand.
OPQRST
 Onset: Began just 20 minutes prior while
mowing his lawn
 Palliative: Nothing makes it better
 Provocative: Made worse with exertion
 Quality: Pressure; feels like someone is sitting
on his chest
OPQRST
 Region: Center of his chest
 Radiation: Moves into his back, left shoulder
and arm, and left side of jaw
 Severity: 8/10
 Time: Constant since it began
Management Priorities
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Call for ALS Intercept
Begin rapid transport
Place patient on Oxygen at 15 LPM via NRB
Administer 325mg Aspirin orally
Administer 0.4mg Nitroglycerin SL and reassess
vital signs and pain level
 Nitroglycerin can be repeated twice if needed
 It is imperative to reassess vital signs after
medication administration
Medication Considerations
 Aspirin should not be administered to patients
who are unable to swallow, who are allergic
to it or who are vomiting.
 Nitroglycerin should not be administered to
patients with a blood pressure of less than 100
systolic or who have taken erectile
dysfunction medications in the last 24 hours.
 If in doubt contact medical control!
Reassessment
 EMS Providers administer Oxygen, ASA, and 2 sprays
of Nitroglycerin.
 Vital signs: Blood pressure 110/70, Pulse 110,
Respirations 20; O2 Sat 100% on oxygen.
 Skins have dried up slightly and patient does not
appear as pale.
 Patient says he is still having pain, but is now
reporting it at a severity of 4/10. It is still radiating
into all areas reported.
Case Summary
 After 10 minutes, ALS service arrives and
initiates IV, administers morphine and
identifies an Acute Myocardial Infarction upon
performing of a 12-lead EKG.
 Patient is transported to a facility with Cardiac
Cath capabilities and receives 2 stents.
Review
 If doing this CE individually, please e-mail your
answers to:
 [email protected]
 Use “May 2014 CE” in subject box.
 IDPH site code: 06-7100-E-1214
 You will receive an e-mail confirmation. Print
this confirmation for your records and
document in your PREMSS CE record book.
True or False? Do you agree with
your original answers?
Patients with a history of substance abuse have
a right to effective pain management.
1. True
Infants and small children have such poorly
developed nervous systems that they rarely feel
severe pain.
2. False
True or False?
Comparable physical stimuli produce
comparable pain in all people.
3. False
The more prolonged the pain or the more
experience a person has with pain, the better
the tolerance of pain.
4.
False
Patients do not expect to have their pain
relieved.
5.
True
True or False?
Lying about the existence of pain is very
common.
6. True, but more likely to down play the pain
than make it worse than it was.
Pain is largely an emotional or psychological
problem, especially in a patient who is highly
anxious or depressed or who has an unclear
physical cause for pain.
7. False
All real pain has an identifiable physical cause.
8. False
True or False?
Sedation or sleeping is an indicator of pain
relief.
9. False, people can sleep and still be in pain
Pain is whatever the patient says it is.
10. True
True or False?
The EMT’s personal values and intuition about
the trustworthiness of the patient is a valid tool
in identifying if the patient is lying about pain.
11. False
Visible signs, either physical or behavioral,
accompany pain and can be used to verify its
existence and severity.
12. False