Pain Relief CPG

Question 1

Care Objective Pain Relief CPG

Answer 1

To reduce the suffering associated with pain to a comfortable level

Question 2

What is the preferred mode of analgesia? What does this mean?

Answer 2

Multimodal. It means giving smaller amounts of different drugs instead of a larger does of one to achieve better pain relief.

Question 3

How do we determine the adequacy of analgesia?

Answer 3

Communication and conformation from the patient that their pain is under control. Assessing the signs and symptoms of pain can also be considered.

Question 4

If a patient remains in pain, what should ALS paramedics do?

Answer 4

If max doses have been given the paramedic should consult with the clinician for further doses of pain medications.

Question 5

If there is IV access and a patient in moderate pain what is the preferred combination of medications?

Answer 5

IV opioids and paracetamol

Question 6

What is the preferred method of pain relief in elderly/frail patients and why?

Answer 6

IV route over the IN route as IN provides a more variable result in this population
IN can still be considered to extradite time to first dose or if IV access is unsuccessful or unavailable

Question 7

When is IN ketamine/Fentanyl the preferred pain management approach for moderate pain?

Answer 7

IV access is non-available or not required

IV access is delayed or unsuccessful

Question 8

When is IN ketamine the preferred approach to moderate pain?

Answer 8

IN Ketamine if first line opioids have little affect

IN ketamine is the preferred approach if the patient is tolerate to opioids, declines them or they are contraindicated

Question 9

When should oral paracetamol be administered?

Answer 9

Always in conjunction with other pain medications if it is not contraindicated and the patient isn’t likely to need immediate or emergency surgery.

Question 10

If a patient has moderate pain, when can you give IM morphine?

Answer 10

if IN fentanyl and ketamine are non-effective or contraindicated and you can’t gain IV access

Question 11

When should methoxyflurane be used?

Answer 11

Preferred for procedural pain
As a their line pain management option
In conjunction with other pain management to optimise pain relief

Question 12

What is there preferred approach to serve pain?

Answer 12

IV opioids and ketamin IN

There is no need to give only opioids first. Ideally wait 2-5 minutes to watch for patient reaction.

Question 13

When can IV ketamine be used?

Answer 13

MICA- in preference to IN

ALS- after consult if initial IN is not adequate

Question 14

What is moderate Procedural pain?

Answer 14

Pain due to splinting and reducing fractures, difficult egress and moving to stretcher

Question 15

What is severe procedural pain?

Answer 15

Prolonged extraction or manipulation of severe musculoskeletal injury

Question 16

What pain relief is suitable for cardiac chest pain?

Answer 16

IV opioids
IN fentanyl if IV unavailable
Morphine or Fentanyl IM if IV/IN not available with or without Methoxyflurane

Question 17

When is fentanyl preferred to morphine?

Answer 17

Hypotension
Respiratory depression 
Morphine contraindicated 
Short duration desirable 
Nausea/Vomiting 
Sevre Headache

Question 18

Why should caution be taken if admin of ketamine to elderly/frail patients and adolescents?

Answer 18

There is greater side effects potential

Use IN fentanyl preferentially

Question 19

Why should care be taken when administering ketamine to patients with a history of anxiety/psychosis?

Answer 19

Due to potential side effects

Question 20

What populations should receive ketamine with extra caution?

Answer 20

• Elderly/frail patients
• Adolescents
• Pt with an Anxiety or psychosis history

Question 21

How are side effects from medications managed?

Answer 21

Respiratory depression from opioids- IV naloxone
Hyper salivation from ketamine- Suction or MICA atropine
Emergence reactions- Midazolam

Question 22

What is the mild pain action?

Answer 22

Paracetamol

Question 23

What is the First line action for moderate pain?

Answer 23

IV access: Opioids
No IV access or delayed: IN fentanyl or ketamine
All: Paracetamol unless contraindicated

Question 24

What is the second line action for moderate pain?

Answer 24

Ketamine IN

Morphine IM

Question 25

what is the third line pain relief for moderate pain?

Answer 25

Methoxyflurane

Question 26

What is the First line action for severe pain?

Answer 26

IV access:

Morphine or fentanyl IV and Ketamine IN after 2-3 does ketamine consult for IV

Question 27

What is the second line action for severe pain?

Answer 27

IV access unsuccessful or delayed:
Fentynal IN
Ketamine IN 
Morphine IM
Methoxyflurane

Question 28

Paracetamol Dose

Answer 28

1000mg

Elderly/frail/<60kg 500mg

Question 29

Methoxyflurane Doses

Answer 29

3ml repeat 3ml for max 6ml

Question 30

Fentanyl doses

Answer 30

IV: 50mcg repeat at 5/60min consult after 200mcg
IN: 200mcg repeat 50mcg at 5/60 for a max of 400mcg or Elderly/frail 100mcg repeat at 5/60 for a max of 200 mcg
IM: 100mcg repeat 50mcg at 15/60 once or Elderly/frail 1mcg/kg single dose

Question 31

Morphine Doses

Answer 31

IV 5mg repeat at 5/60 consult after 20mg

IM 10mg repeat 5mg at 15/60 once or Elderly/frail 0.1mg/kg single dose

Question 32

Ketamine doses?

Answer 32

IN: 75 mg repeat 50mg @ 20/60 no max or Elder/frail 50mg repeat 25mg @ 20/60 no max dose
IV: Consult

Question 33

can Ketamine be given IM?

Answer 33

Yes if IV and IN ketamine are unavailable or not adequate

Question 34

What is the optimum volume for IN ketamine absorption? How you you achieve this?

Answer 34

0.3-0.5 millimetres is optimal, it might be good to consider doing a half dose in each nostril to obtain maximum affect