Transcript Oh What a Relief It Is!

Oh What a Relief It Is!
Pain Management in EMS
Laurie A. Romig, MD, FACEP
Medical Director
Pinellas County (FL ) EMS
‘‘We must all die. But that I can save
a person from days of torture, that is
what I feel is my great and ever-new
privilege. Pain is a more terrible lord
of mankind than even death itself.’’
-Albert Schweitzer
Objectives
Provide a better understanding of how
badly we and the rest of the medical
profession handle pain
Identify some of the barriers to
better pain management for all patients
Describe some common pharmacological
pain interventions
Describe some nonpharmacological pain
interventions
Survey says:
Do you believe that prehospital pain
management is a:
High priority and important goal
Nice to do if you have the time, but not a
priority
Not at all important
Not our job or our problem (nobody ever
died of pain)
Survey says:
How many of you have:
Protocols for pain meds before or without
medical control contact
Protocols for pain meds only after medical
control contact
IV opiates
Intranasal opiates
Other non-opiate analgesics such as
ketorolac (Toradol)
BLS measures only
Survey says:
How well do you think your service does
with pain management?
We do great. Nobody suffers unnecessarily
Pretty good, but we could do better
Not very well
What pain management?
Prevalence of Pain
Studies show that pain of some type is
a presenting complaint for up to 70% of
all ED patients
The percentage for EMS is probably
similar.
One study showed that 20% of EMS patients
complain of at least moderate to severe pain
Other studies show that all medical
practitioners, including EMS are poor
pain evaluators and managers
JCAHO now recognizes pain evaluation
as the “fifth vital sign” and judges
hospitals on their pain management
policies
In many cases, pain relief is the
primary expectation of our patients
In many cases, it is the ONLY thing
that we can offer the patient other
than transport to the hospital
Pain management is often neglected or,
at best, delayed in Emergency
Departments
EMS Literature
1073 patients
with suspected extremity fractures
only 1.8% were administered analgesics
17% received ice packs
25% received air splints
Akron Fire Department
Published 2004
EMS Literature
124 patients
with ED diagnosis of
hip or lower extremity fractures
18.3% were administered field
analgesics
91% received analgesia in the ED
(ED patients - 2 Hour Delay)
William Beaumont Hospital, Royal Oak, Michigan
Published 2002
EMS Literature
128 elderly patients
with field diagnosis
femoral neck fractures
51% received field pain management
Only 2 patients received splints in the field
Westmead Hospital, Sydney, Australia
Published 2003
Why is oligoanalgesia so
prevalent?
Few EMS textbooks devote significant
attention to pain management
EMS education on pain management
lacking
Many EMS systems do not have pain
management protocols
Why is oligoanalgesia so
prevalent?
EMS personnel want to avoid
conflict with ED physicians
ED physicians want to avoid
conflict with surgical consultants
Myths About Pain Management
Care providers can accurately assess a
patient’s pain by observation
Pain affects all people in the same way
Everyone responds to analgesics in the
same way
Analgesia can create difficulty in assessing
abdominal pain and other clinical conditions
Myths About Pain Management
Patients become unable to give informed
consent
Use of narcotics in acute pain leads to
increase in addiction
Analgesic use in the field is unsafe
Myth: Care providers can accurately
assess pain by observation
Self-reporting is actually shown to be
the most accurate reflection of pain
intensity, NOT the care provider’s
opinion
Care providers are influenced in their
subjective evaluations by other patient
factors and by their prior personal and
professional experience with pain
Myth: Pain affects all people in
the same way
Pain perception is affected by:
Age (KIDS DO HURT AND THEY DO
REMEMBER IT!)
Gender
Race
Culture
Emotions
Cognitive state
Previous experience
Pain Assessment
Objective measures of pain ratings
improve pain management
Help to balance imprecise clinician pain
assessment
Assist in tracking success of pain
management
Are available for both adult and pediatric
ages, even down to neonates!
Pain Assessment
Numeric Rating Scale
0-10
0 = No pain
10 = The worst pain you can imagine
Requires verbal and cognitive ability
Pain Assessment
Visual Analog Scale
10 cm line with left end being “no pain”
and right end being “worst pain imaginable”
Have patient mark their pain level on the
line
Pain level measured in millimeters
Requires vision, cognition and relatively
large amount of space to perform
Pain Assessment
Verbal Rating Scale
None, mild, moderate, severe, unbearable
Requires cognitive ability
Pain Assessment
Wong-Baker FACES Scale
Works well for pediatrics
Also works well for some adult patients
unable to perform other scales
Also comes in a 0 to 10 format
Myth: Everyone responds to
analgesics the same way
Many factors can affect how a given
drug and dose will affect different
people
Body weight
Lean vs. total
Hemodynamic status
Drug tolerance
Metabolic rate
Concurrent drug use
Myth: Analgesics can create
difficulty in physical examination and
diagnosis
A number of studies have shown that
early administration of analgesics
Allows patients to relax
Removes voluntary guarding
Permits better assessment of
localized tenderness
Myth: Analgesics can create
difficulty in physical examination and
diagnosis
Administration of morphine to
pediatric patients with abdominal
pain did not affect the clinician’s
ability to recognize children with
surgical conditions
Published 2002
Myth: Analgesics can create
difficulty in physical examination and
diagnosis
In a survey of emergency medicine physicians
ED physicians believe judicious use of
pain medication does not compromise
physical exam
BUT the majority withheld analgesics
until after evaluation by the general
surgeon
Published 2000
Myth: Patients become incapable
of giving informed consent
Multiple studies show that patients
retain their ability to give
informed consent
despite the effects of analgesics
Myth: Use of narcotics in acute pain
leads to an increase in addiction
NO research supports this
Assumption is often based on the fact
that many people appear to become
“drug-seekers” after an acute injury
In fact, these “drug-seekers” are often
only the victims of inadequate pain
management (oligoanalgesia) and a medical
culture that does not recognize it’s own
limited understanding of pain issues
A note about “drug-seekers”
Check with your medical director about
his or her philosophy
In general, EMS should NOT be
attempting to determine if a patient is
a drug-seeker
Especially without an on-going familiarity
with the patient
Doing so may cause you to unfairly undertreat patients
Myth: Analgesics are Unsafe
One study evaluated 84 cases using
small doses (2-4 mg) of morphine
Only one case of MS induced
respiratory depression was found
Published 1992
Myth: Analgesics are Unsafe
Another study reviewed 131
air-transported patients
who received fentanyl.
There were no untoward events
Published 1998
Myth: Analgesics are Unsafe
2129 patients
administered fentanyl in the field
12 patients (0.6%) had a VS abnormality
due to fentanyl administration
Only 1 patient required a recovery
intervention
Published 2005
Remember that any
analgesic (and most EMS
drugs) CAN be unsafe in the
field if used outside of
reasonable protocols and
standard of care boundaries
and without appropriate
quality management.
Let’s take a break!
Safe Use of Analgesics
Understand the concepts of time of
onset of action and peak effect
(pharmacodynamics) and the values for
each drug you use
Giving additional doses of medication prior
to a previous dose taking effect puts you
at risk for creating a problem for the
patient
Safe Use of Analgesics
Slow and steady is better than hard
and fast
Titrate small doses at appropriate
intervals
Safe Use of Analgesics
Beware the effects of combining drugs
Particularly when added to not taking
pharmacodynamics into account, adding
one CNS depressant or hemodynamic
depressant drug to another can create
unpredictable changes
Safe Use of Analgesics
Don’t forget to ask about medication
allergies, current medications and when
they were last taken
Remember to look for Fentanyl patches!!
Adding IV opiates on top of recently taken
oral sedatives, analgesics or muscle
relaxants may cause unpredictable additive
effects as well
Safe Use of Analgesics
Know your pain management goal
Does your pain management protocol have
a goal?
”Make the ride more bearable”?
“Decrease pain by 50%”?
“Decrease pain to “x” or less”?
“Make patient painfree”?
Your goal may actually be different for
different types of patients
Safe Use of Analgesics
Reassess the patient (including pain
scale) frequently
Document carefully (including pain scale)
Take the patient’s hemodynamic state
into account if your medication may
affect it
Safe Use of Analgesics
Always give complete report to ED
staff regarding drugs given, time given,
and results or adverse reactions
It can be difficult to sort out whether
changes in level of consciousness or
development of respiratory or circulatory
compromise are due to the drug or to
underlying illness or injury without good info
on timing and sequence
Who should receive analgesics?
As always, go by your own protocol
Your local protocol may depend upon
your medical director’s attitudes and
experience with pain management and/or
your medical community’s
Who should receive analgesics?
Your protocol may (and should) address
Abdominal pain patients
Pediatric/infant patients
Headache patients
Trauma patients (particularly multiple
blunt trauma)
Hemodynamically unstable patients
The elderly
Short transport time patients
Who should receive analgesics?
Your protocol MAY contain minimum
pain level requirements or specifications
for acute versus chronic pain
ED docs may complain about what they
perceive of as “minor” patients receiving IV
analgesics
They may also complain about chronic or
subacute pain patients receiving IV
analgesics
Who should receive analgesics?
Remember that nonpharmacological pain
management methods are usually safe
and can be surprisingly effective
Ice or heat
Elevation
Splinting/positioning
Emotional support
Distraction (guided imagery, biofeedback,
breathing exercises)
Common Prehospital Analgesics
How do I choose?
Desirable characteristics for EMS analgesic
Quick acting (short onset and peak effect)
Short duration
Minimize side effects
Hypotension, respiratory suppression,
emesis, etc.
Easy to administer
Multiple administration routes available
Reversible
Inexpensive
How do I choose?
Take patient allergies into consideration
Take patient condition into
consideration
Use the least hemodynamically active agent
if patient is unstable
Sometimes it’s a crap shoot!
Individual patients may react better to
some drugs than to others, but usually it’s
still just a matter of giving ENOUGH drug
My Favorite…
Fentanyl
Fentanyl (Sublimaze)
An opiate with sedative and analgesic
properties
Used in OR’s for many years, has
become much more common in ED’s and
EMS in last 5 years or so
May be used IV, IM, intranasal,
transmucosal, and transdermal
May be used safely for both adults and
children
Fentanyl
May be used for pain management (including
cardiac ischemia), sedation, and as part of
facilitated intubation and/or rapid sequence
intubation
Reversible with Narcan
Causes less emesis than Morphine
Inexpensive
No cross-reactivity in morphine allergic
patients
100 x as potent as morphine
Fentanyl
Generally minimal effect on blood
pressure, heart rate and ventilatory
drive
Helps to blunt  HR and BP associated
with intubation
Chest wall rigidity or muscle twitching
can occur
Should be reversible with Narcan
Most side effects result from pushing
the medication too quickly
Fentanyl
Onset of action
IV: 1-2 minutes
IM and IN: 7-15 minutes
Peak effect
IV: several minutes
IM and IN: 15 minutes
Duration of effect
IV: 30-60 minutes
IM (and IN?): 60-120 minutes
Fentanyl
Dosing for pain management
1-2 mcg/kg IV over at least one minute
q 1-3 minutes for hemodynamically stable
peds and non-elderly adults
Some services deliver in 50 mcg
increments rather than by weight
Recommend starting with 0.5 mcg/kg for
elderly and hemodynamically unstable
patients
Note: For all opiates, reduce doses if using
another CNS depressant concurrently.
Fentanyl
Dosing for pain management
IM dose: Few recommendations in
literature. Would start with IV dose but
remember that it will take MUCH longer to
have initial and peak effect
IN dose: Depends on concentration you
have available.
Dr. Tim Wolfe recommends 1.5 mcg/kg per
dose, but can only administer max of 1 cc of
fluid per nostril
Fentanyl
Dosing for sedation
Light, anxiolytic sedation: 1 mcg/kg IV
Deep sedation for procedures: 2-3 mcg/kg
IV (fentanyl alone) or 1-2 mcg/kg IV
(fentanyl with another agent)
Once you get above 3-4 mcg/kg you’re
looking at general anesthesia level doses!
Morphine
An opiate with sedative and analgesic
properties
Still considered by many to be “The
Gold Standard”
May be used IV, IM, SC or orally
May be used safely for adults and
pediatrics
Morphine
Reversible with Narcan
More likely to cause emesis than
Fentanyl
Inexpensive
Opioid potency is compared to 10 mg of
morphine IV
10 mg morphine IV equivalent to 100 mcg
(0.1 mg) of fentanyl IV
Morphine
More likely to cause respiratory
depression, hypotension, bronchospasm
and tachycardia than fentanyl
due to histamine release
May actually increase intracranial
pressure
Morphine
Onset of action
IV: 5-20 minutes (longer than fentanyl)
IM: ?
Peak effect
IV: 30 minutes (longer than fentanyl)
IM: ?
Duration of action
IV: 2-3 hours (longer than fentanyl)
IM: 3-5 hours
Morphine
Dosing for pain management
0.05-0.3 mg/kg IV
Many protocols call for increments of 2-4
mg IV titrated for adults, others for doses
of 5-10 mg IV
May be wise to do a “test dose” of 1-2 mg
to gauge hemodynamic effect
Typical pediatric dose is 0.1 mg/kg IV
Typical IM dose for adult is 5-10 mg
Nitrous Oxide
Inhalation agent with analgesic and
anesthetic properties
In use for many years
Usually 50/50% mix with oxygen
Onset and duration of action: 3-5
minutes
Can be self-administered
Nitrous Oxide
Do not secure mask to the patient’s
face
Mask will fall away if patient becomes
oversedated
Effects rapidly wear off
Side effects mostly nausea/vomiting
Contraindicated for suspected
pneumothorax, possible bowel obstruction
and other situations where gas may be
entrapped in a closed space of the body
Nitrous Oxide
Discontinued in some EMS systems
because of abuse problems
Potential for gas to enter the ambient
atmosphere and affect EMS providers
Butorphanol (Stadol)
Opiate agonist-antagonist
Because of this, Stadol is thought to
create less respiratory depression and less
risk of drug dependence with chronic use
May be used IV, IM or IN
Can cause withdrawal symptoms if used in
patients who are narcotic dependent
May also cause need for increased doses
of other narcotics for subsequent pain
management and/or anesthesia
Butorphanol (Stadol)
Relatively unpredictable effectiveness
Nalbuphine (Nubain) is similar drug
Both are considered less than ideal
prehospital drugs
Butorphanol (Stadol)
Onset of action
IV: 1 minute
IM/IN: 15 minutes
Peak effect
IV: 4-5 minutes
IM: 30-60 minutes
IN: ?
Butorphanol (Stadol)
Duration of action
IV: 2-4 hours
IM: 3-4 hours
IN: ?
Stadol dosing
IV/IM: 2-4 mg
IN: 1-2 mg
Ketorolac (Toradol)
Nonsteroidal anti-inflammatory agent
Can be administered IV or IM
Expensive
Effective in disorders such as kidney
stones and musculoskeletal disorders but
is NOT better than opiates in either
Dose 30 mg IV or 60 mg IM
Ketorolac (Toradol)
Few obvious acute side effects (such as
hypotension, respiratory depression,
emesis) BUT
Potentially significant hidden side
effects
Platelet inhibitor activity can worsen
bleeding for up to a week after single
injection
Renal toxicity (especially in elderly)
Before we finish…
You can download this Powerpoint from
www.jumpstarttriage.com
Go to the The Other Dr. Romig page from
the home page and click on the appropriate
link at the bottom of the page
You’re also welcome to any of the other lectures listed. I
just ask that appropriate attributions are made if you use
them for presentation or research purposes. Please contact
me with any questions or corrections.
Summary
Pain management can and should be a
major intervention for prehospital
providers
There are a number of myths regarding
pain management that are being
factually debunked
But not all healthcare providers are aware
or convinced
Summary
Prehospital pain management CAN be
performed safely when appropriate drug
choices, protocols, education,
documentation and quality management
tools are integrated
What would you want if YOU or a loved
one were the patient in pain?
Questions?
Laurie A. Romig, MD, FACEP
[email protected]