Learning objectives

After reading this article you should be able to:

C outline the challenges to pain management in the pre-hospital

environment

C discuss a method of pain assessment in the pre-hospital

TRAUMA

Pain priorities in pre-hospitalcare*

Charlotte Small

Dominic Aldington

environment

C list the pain management strategies in the pre-hospital

Abstract environment Pain management in the pre-hospital environment is a priority following

life- and limb-saving manoeuvres. Pain should be assessed and docu-

mented then managed according to a multimodal model. Even in the

context of environmental challenges and limited resources, pharmacolog-

ical, physical and psychological interventions can all be used to provide

effective analgesia and relieve suffering prior to and during transfer to

hospital.

Keywords Multimodal management; pharmacological, physical and

psychological treatment; trauma

Royal College of Anaesthetists CPD matrix: 1D01, 1D02

General principles

The management of pain in the pre-hospital environment pro-

vides a number of challenges to the pre-hospital clinician. These

include:

� variety of injuries

� patient co-morbidities

� patient anxiety

� exposure to environmental extremes leading to hypo- or

hyperthermia

� significant physiological changes rendering some routes of

administration unreliable

� isolation from specialist advice

� limitations of pre-hospital practitioners’ knowledge and

expertise

� exacerbation of pain by patient movement, vehicle vibra-

tion, motion sickness

� danger to patient and physician.

Being injured hurts; more than two-thirds of military casualties

describe their pain as moderate or severe at the point of injury.1

After treatment of life- or limb-threatening injuries, and assess-

ment and management of respiratory, haemodynamic and

neurological systems, pain management should be considered a

priority.

The ideal pre-hospital analgesic agent would be available to

all pre-hospital practitioners, have a rapid onset, be easy to

titrate, relieve moderate and severe pain and be free of side

* The views expressed in this work are those of the authors and are not

necessarily those of the Defence Medical Services or the Ministry of

Defence.

Charlotte Small FRCA is an Anaesthetic Research Fellow at the Queen

Elizabeth Hospital, Birmingham, UK. Conflicts of interest: none declared

Dominic Aldington FRCA FFPMRCARAMC is a Consultant in Pain Management

at theHampshire Hospitals Foundation Trust,Winchester, UK. Conflicts of

interest: none declared

ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:9 402

effects such as nausea and vomiting, respiratory and haemody-

namic depression. Unfortunately, none of the currently available

analgesics matches these requirements so pain relief should be

provided following careful riskebenefit analysis.

A survey of UK civilian and military pre-hospital care doctors

found a general agreement that the goals of pre-hospital anal-

gesia should be:2

� pain scores of no greater than mild (3 or less on a 0e10

numerical rating scale)

� pain relief to be achieved within 10 minutes

� verbal contact to be maintained with the patient

� analgesia should not incur the need for artificial

ventilation.

Assessment

Timely and accurate pain scoring allows assessment of analgesic

requirement and appraisal of analgesic efficacy. There are a

number of pain scales that can be used to assess acute pain and,

ideally, the scale used should be the same as that used in the

receiving unit. Essentially, the chosen scale should be easy to use

and reproducible (for an example see Table 1). Scores should be

documented clearly both prior to and following analgesic

administration and handed over to the hospital team, ideally on a

standardized document. Whichever score is used, anything more

than one-third of the maximum is a ‘failure’.3

Management

In common with all varieties of pain management, a multimodal

approach will prove to be the most effective. Optimum man-

agement of acute pain in the pre-hospital environment encom-

passes minimizing the cause of the pain as well as physical,

psychological and physiological interventions (Figure 1).

Pain assessment scale

Pain score Level of pain

3 Continuous pain at rest, severe on movement

2 Mild pain at rest, moderate on movement

1 No pain at rest, mild on movement

0 No pain at rest or on movement

Table 1

� 2014 Elsevier Ltd. All rights reserved.

Remove causeSplintingBurns dressingsVacuum mattressSecure stretcher

Physical methodsAcupressureManipulationCool/heat packs

Drug treatmentsNon-opioidOpioidRegional techniques

Psychological methodsEducationReassurancePatience

Pain management strategies

PAIN

Figure 1

TRAUMA

Minimizing the cause

Immobilization can be key to relieving pain. Fractured limbs

should be splinted, the patient can be immobilized on a vacuum

mattress, the patient should be secured carefully on a stretcher

and all unnecessary movements should be avoided. The pain

of superficial burns can be reduced by the application of a

cellophane-type, non-adherent dressing.4

Physical methods

Physical treatments are limited in the pre-hospital environment.

Cooling burns is often possible and cold and heat packs can be

considered for muscular injuries while acupressure may be

beneficial for minor injuries.5

Psychological methods

Pain experienced by physiologically similar injuries can vary

enormously. Indeed, as anyone who has had a paper cut will

understand, level of pain does not correlate with severity of

injury. In the pre-hospital environment, fear and anxiety will

exacerbate pain. Patient communication is of vital importance.

The patient should be reassured and their pain and treatment

options explained clearly.

Pharmacological methods

Using a multimodal approach, analgesia provision can be guided

by the use of a pain ladder. This was initially developed by the

Moderate pain

Mild pain

Severe pain

Paracetamol +/

Paracetamol +/– Non-steroidal an

Pain ladder

Figure 2

ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:9 403

World Health Organization for use on cancer pain but is still of

value for treating all types of acute pain (Figure 2). For those

with moderate or severe pain, analgesia should be provided from

the top level and work down, rather than starting at the bottom

and working your way up.

Simple analgesia and non-steroidal anti-inflammatory drugs

(NSAIDs)

There are almost no contraindications to paracetamol, and it can

be given via a number of routes. Likewise, NSAIDs can be given

orally, rectally, intravenously and intramuscularly. Non-selective

NSAIDs can cause platelet inhibition, potentially increasing

bleeding tendency so a selective cyclo-oxygenase-2 inhibitor may

be preferable in more severe injuries.

Opiates and opioids

Morphine, fentanyl and tramadol are all used in the pre-hospital

environment, however a systematic review failed to conclude

that one worked better than the other. Their onset is relatively

rapid, however 60e70%of patients reportmoderate or severe pain

10 minutes following administration.2 Intravenous morphine has

long been the gold standard for management of severe pain. It can

also be given via intraosseous and intramuscular (IM) routes;

10mg IM autojets are issued to BritishMilitary personnel on active

duty for the purpose of self-administration. The reduced gastric

emptying seen in trauma may render the oral route unreliable.

Fentanyl is highly lipid soluble, which makes it suitable for

trans-mucosal administration. Intranasal and buccal formula-

tions are available and the latter can be used as patient-controlled

analgesia although good technique is required.6

Ketamine

Ketamine is a powerful dissociative analgesic and anaesthetic

agent, which provides profound analgesia at the expense of sig-

nificant neurological side effects. It should only be used by

doctors trained and proficient in its use. Ketamine can be used

intramuscularly as well as intravenously and, unlike opiates,

may not cause hypotension and cardiovascular depression. It

raises cerebral metabolic rate and its use in head injuries remains

contentious.7

Inhalational agents

In the UKEntonox�, a 50%mixture of nitrous oxide and oxygen, is

carried by pre-hospital teams. Relying on patient cooperation, it

– NSAID +/– Mild opioid

Paracetamol +/– NSAID +/– Strong opioid

ti-inflammatory drug (NSAID)

� 2014 Elsevier Ltd. All rights reserved.

TRAUMA

provides rapid analgesia for all levels of pain but can cause

giddiness, nausea and vomiting.8 Pain returns rapidly once

the gas is removed. It should not be used if a pneumothorax or

diving-related injury is suspected due to its high solubility allow-

ing it to diffuse into and increase the volume of gas-filled cavities.

Ambulance crews in Australasia commonly use methoxyflu-

rane, an inhalational anaesthetic agent with analgesic and

sedative properties. Evidence for its use is sparse with only one

cohort study to date reporting benefits in the absence of signifi-

cant complications9 and it is not currently used in the UK or USA.

Regional anaesthesia

Nerve blocks can be used to provide localized analgesia to relieve

the pain of limb injuries, without subjecting the patient to side ef-

fects of systemic analgesia. They rely on the presence of a skilled

practitioner and are a challenging undertaking in the pre-hospital

environment. Whilst a number of nerve blocks and approaches

have been investigated, current evidence suggests that the only

block of benefit may be the fascia iliaca block, a landmark-based

techniquenot requiring anerve stimulator. Evidence for its use is, so

far, only supported for the management of femoral fractures.10 A

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FURTHER READING

Greaves I, Porter K, Garner J. Analgesia and anaesthesia for the trauma

patient. In: Greaves I, Porter K, Garner J, eds. Trauma care manual. 2nd

edn. Edward Arnold Publishers Ltd, 2009.

� 2014 Elsevier Ltd. All rights reserved.