Pain Management Flashcards
Pain Management - Definition
Significant traumatic injury or severe pain associated w/ other medical causes
Goal of Care
Increase comfort and decrease anxiety. Transport for definitive diagnosis and treatment
Overview
Addressing and managing a patient’s pain is one of the most significant contributions paramedics can make in the out of hospital setting and is a major goal of our care. Addressing pain can calm the patient and assist in assessment and management. Making the patient more comfortable also helps him/her understand that you are trying to help. This usually leads to better cooperation
Typical Measures
- Reassurance
- Gentle handling
- Control of temperature (avoid shivering) by using blankets or warming the ambulance
- Positioning of the patient or limbs ensuring adequate support and padding
- Splinting of the limb to avoid motion
- Application of cool dressing to small burns (while avoiding cooling of the patient)
Guiding Principles
Pain can be effectively managed in many pts in the pre-hospital setting
Assessing for and attempting to manage a pts pain is a mandatory part of every pt encounter
Nitrous Oxide w/ O2
Nitrous oxide is an effective analgesic, especially when combined w/ reassurance and positive enforcement
Contraindications - come w/ pathophysiology of gas exchange and absorption: hypoxia, trapped gas (pneumothorax, bowel obstruction)
Nitrous oxide can cause hypoxemia due to displacement of oxygen in the alveoli as the nitrous diffuses out of the blood stream
High flow O2 by simple face mask after nitrous use should be provided to all pts to avoid hypoxemia
Methoxyflurane (Penthrox)
Methoxyflurane is a volatile, self-administered inhalation analgesic indicated for short term pain relief
- only to be used for pts who are able to understand instructions
Ibuprofen
- is a non-selective NSAID that inhibits the synthesis of prostaglandins resulting ini analgesic and anti-inflammatory actions
- also has antipyretic properties
- effective at reducing mild to moderate pain due to acute inflammation and tissue injury
Contraindications - allergy, bleeding disorders thrombocytopenia, current GI bleeding or peptic ulcers, dehydration, renal impairment, NSAID induced asthma, heart failure and 3rd trimester pregnancy
Caution - in pts w/ asthma, hepatic dysfunction, a hx of GI bleeding or ulcer, taking ACEIs/ARBs or on diuretics and anticoagulants
- should be taken following food or milk to minimize GI adverse reactions
- should consider previous doses of analgesia by the pt, carer or parent
- may be used in conjunction w/ acetaminophen
Acetaminophen
Acetaminophen is an analgesic and antipyretic but does not possess significant anti-inflammatory properties like ibuprofen
- can be combined w/ ibuprofen for synergistic analgesic effects
Contraindications - allergy, severe liver impairment or disease, pts less than 1 month old
- should consider previous doses due to potential hepatic toxicity associated w/ high doses
- Adults should not have more than 4
grams in a 24hr period
- Adults should not have more than 4
Fentynal
is an opiod analgesic, similar to morphine as are the side effects - can be reversed w/ naloxone
- is more potent than morphine and lower doses can be used to achieve the same desired analgesic effect
- is not structurally related to morphine - can be used when there is a true morphine allergy
- preferred over morphine w/ pt is hypotensive - less likely to cause hypotension as it does not cause histamine release
- BP may still decrease through decrease of sympathetic tone - BP is still to be monitored after giving fentynal
- useful in relieving all types of pain, regardless of etiology
Ketamine
- provides dose dependent analgesia, sedation and dissociative effects
- is well absorbed when admin’d intranasally using an atomizer making it easy and safe to administer and ideally suited to PCP practice
- preferred parenteral analgesic when there is no vascular access
- biggest advantages - ability to continue to breath, retain protective airway reflexes, tendency to elevate BP due positive catecholamine effects
- also provides direct bronchodilation making it preffered sedative of choice in asthmatics/COPD
- should not be considered the first line analgesia for pain
Intervention Guidelines - EMR/PCP
- Keep pt at rest
- Position of comfort
- Splint/support any injured extremity
Analgesia
- Nitrous Oxide - self admin’d to effect
PCP
All above, plus;
- Ibuprofen 400mg PO repeat once after 6hrs
- Acetaminophen - 500-1000mg PO repeat once after 4hrs
- Ketamine - 0.75mg/kg IN (max volume 1mL per nostril)
repeat once in 20mins at 0.5mg/kg
**Safety alert: Remember to account for the 0.1ml dead space in the mucosal atomizer device (MAD) to ensure the accurate dose is administered and documented
Intervention Guidelines - ACP
All above, plus;
- Fentanyl
- Ketamine
Alternate routes - IV/IO
Further Care
- Positioning
- Splinting/casting
- Opiods
- Pt controlled analgesia (post operative)
