PrehospitalPain Management

Protocols and Ideas

Michael W. Dailey, MD FACEP

Regional EMS Medical Director

Associate Professor

of Emergency Medicine

Albert Schweitzer - 1931

“We all must die. But that I can save him from days of

torture, that is what I feel as my great and ever new

privilege. Pain is a more terrible lord of mankind than

even death itself.”

Disclosure

No academic conflict of interest

No financial conflict of interest

FDA Off-label use of a medication will be discussed

Have you ever been trapped in a small box with someone who is Crying? Screaming? Sobbing?

Objectives

Pain management is a central focus in hospital

based-medical care.

Currently, time to pain management is also an

important metric for the in-hospital management of

patients with long-bone fractures.

If a patient has received pain management from EMS,

it not only provides improved care, but also assists in

the ED management of the patient.

Federation of State Medical Boards Model Policy—2004

Policy states the under-treatment of pain is a

departure from an acceptable standard of practice

Inappropriate pain treatment includes:

– Nontreatment

– Undertreatment

– Overtreatment

– Continued use of ineffective treatments

JCAHO Pain Standards

Patients have the right to appropriate assessment and

management of pain

Institutions must respect and support patients’ rights

to pain management

Patients have a right to expect that their pain reports

will be believed and to receive a quick response

NAEMSP Position Paper

Mandatory pain assessment

Indications for pain management

Alternatives for pain management

Patient monitoring

Transfer of patient information

Quality improvement and medical oversight

Research

Began with cancer pain

Extended to all acute and chronic pain syndromes

Track record is appalling

Review of >7000 articles

“most” of 23 million post op patients inadequately

treated for pain

Specific groups at greater risk

Literature

Hundreds of studies

Women

Children

Elderly

Non-white

Co-morbid disease

History of pain

Bottom line: There has never

been a study that indicated

medical providers did an

adequate job of managing pain!

NEVER!

Why Is Pain Undertreated?

Fear of regulatory oversight (leading cause)

Lack of medical training

Misunderstandings about addiction

Inadequate reimbursement mechanisms

Lack of routine assessment

Misunderstanding about adverse events

http://www.deadiversion.usdoj.gov/pubs/nwslttr/spec2001/page10.htm

Paramedic Attitudes

Objective signs

Potential malingering

Ambivilence about the degree of pain control to target

Fear of masking symptoms

Aversion to aggressive dosing

16

Walsh, et al, PEC Vol 17, No 1, Jan-Mar 2013, 78-88

Pain Management in the ED and in EMS

So, What Can You Do?

Learn a range of responses

– Analgesia does not equal conscious sedation

Tailor therapy to patient pain

Be prepared to adjust therapy

Use adjuncts

Work together - discuss plan for analgesia

Start with the easy stuff

Splinting / positioning / reduction*

Ice

IN or IM or IV opioid

In the ED:

Hematoma block

Regional block

Don’t cause more pain before relieving baseline

Parenteral Pain Management

Morphine

Fentanyl

Dilaudid

Demerol

Toradol

Ketamine

Give early

Give enough

Give often enough

What else is done around the country?

Study Objectives

Most Emergency Medical Systems (EMS) have

developed protocols that allow EMS personnel to

administer analgesic medications without prior contact

with a physician.

The prevalence and scope of prehospital analgesia

protocols nationwide is unknown, as is the trend in

practice.

The objective was to assess current prehospital

analgesia practices.

Dailey, Tran and Goldfine, 2014

Methods

An online survey focusing on analgesia protocols and

agents was sent to 50 EMS Directors and Medical

Directors.

Follow up telephone calls were made to assure 100%

compliance.

Data is analyzed with descriptive statistics and

compared to a survey from 2007 that also had 100%

compliance.

Results:

We had 100% survey compliance after email

participation and follow up telephone contact. There is

great variation around the country in the way that

protocols are written and approved.

In 29 states analgesia protocols are statewide, but

there may still be regional or service variation.

Sample 1

If pain management is needed, consider:

a.) Fentanyl 1-2 mcg/kg IV or IM up to 100 mcg initial

dose. Contact physician for orders past 200 mcg

total.

b.) Morphine 4 mg IV initial dose titrated to

pain/pressure. Contact base physician for orders past

20 mg total.

c.) Versed 2 mg IV or IM initial dose, may give

another 2 mg after five minutes if needed.

Sample 2

Consider the use of fentanyl 25-50 mcg IVP every ten

minutes titrated to effect with maximum dose of 200

mcg as long as vital signs are stable.

Consider self-administered fixed dose of 50% nitrous

oxide/oxygen mixture delivered by commercially

available device such as Nitronox.

Sample 3

EMT-Intermediate may administer analgesic for pain:

morphine 2-5 mg IV or IM, repeat every five minutes

as needed to a maximum of 15 mg (as long as vital

signs are stable).

Paramedic may administer alternative analgesic of

choice if SBP > 100 mmHg. (Includes ketorolac,

fentanyl, morphine)

A chest pain protocol...

Nitroglycerin 0.4 mg SL.

Medical Control may authorize additional nitroglycerin

administrations if pain is still unrelieved.

Administer morphine sulfate 2 mg over two minutes IV.

Do not repeat, as additional doses may mask the acute

MI.

30

Let’s look at some specific medications

Fentanyl

Analgesia and euphoria

Rapid onset

Short duration (20 minutes)

Reversible

Respiratory depression

Fentanyl

IN (not FDA approved)

– Dose 1.5-2.5 mcg/kg*

– Maximal effect 3-5 minutes

– Advantages?

IM

– Dose 1-1.5 mcg/kg

– Maximal effect 5-10 minutes

IV

– Dose 0.5 - 1 mcg/kg

– Maximal effect 3-5

minutes

Results - Fentanyl

The use of fentanyl by EMS providers has increased

to 92% of states (n= 46) from 48% (n=24).

Fentanyl - 2007

Fentanyl - 2013

Ketamine

IN* or IM or IV

Fast onset

Maintains airway

reflexes

Dissociative and sub-

dissociative dosing

Emergence reactions

Why Ketamine?

Airway reflex sparing

Supports BP / HR

Additive to opioid

Reduces need for additional opioid

– Dosing 0.1 – 0.2 mg/kg (10 – 20 mg)

– Most patients given low dose ketamine need less morphine

Jennings PA, Cameron P, Bernard S, et al. Morphine and

ketamine is superior to morphine alone for out-of-hospital trauma

analgesia: A randomized controlled trial. Ann Emerg Med, Jan 11,

2012 [e-pub ahead of print].

Ketamine Dosing

IN pain management (not FDA approved)

– 0.5 mg/kg or 50 mg intermittent dosing

IM sedation for acute agitation

– 3-5 mg/kg

IM for pain management

– 0.5 mg/kg

IV for pain management

– 10 to 20 mg over 10 minutes

Results - Ketamine

Ketamine also has a growing use in EMS as well,

with an increase from 6 states to 16.

Indications were not reveiwed in the study

– Some for induction

– Some for disentanglement

– Some for adjunctive pain management

Ketamine - 2007

Ketamine - 2013

Results: Standing Orders

98% of the states allow the administration of opioid

analgesia without contact with a physician, an

increase from a 2007 study 78% (n=39).

Analgesia - 2007

Standing Order Analgesia - 2013

National EMS Practice

Prehospital standing order analgesia is a well-

validated clinical practice is the national standard of

care.

All states with the exception of South Carolina allow

administration of analgesics to patients in pain without

prior contact with a physician.

There is a growing trend to the use of ketamine in

EMS practice.

Fentanyl is the opioid analgesic agent of choice for

EMS.

What else is there?

Non-steroidals

Inhaled agents

Benzodiazepines

Acetaminophen

Ketorolac

Non-steroidal anti-inflammatory

Toxic in renal insufficiency

Effective for musculo-skeletal injuries and renal

stones

Requires physician order in Collaborative Protocols

Midazolam

Not an analgesic

Additive to opioid

Reduces spasm

Amnesia at higher doses

Unpredictable dosing

Requires physician order

Inhaled agents

Methoxy-fluourane

– Patient administer analgesia

– Very effective for minor pain

– Not available in US

Nitrous oxide

– Available for advanced EMT agencies only

– Patient administered

– May reduce need for opioids

Acetaminophen

Now available IV

Reduces need for opioids for post-op pain

Restricted because of cost at AMC

Offers an oral option in the ED or some EMS

agencies

But what about…diversion?

What about Diversion?

Diversion is real

Consider the potential with every medication added

Use engineering controls and procedure to attempt to

control

Realize it might happen

“How could this happen to us?”

MedPage Today Accessed 11/10/2014

What about “Prescription Monitoring”?

Legislation designed for the control of overprescribing

of opioids

Designed to catch bad doctors, bad pharmacists and

bad patients

Does not apply to acute care of patients in severe

pain

What is Optimal EMS Pain Management?

A wide range of options for different situations

– Opioids on standing orders

– Benzodiazepines for spasm +/- standing order

– NSAIDs for renal colic +/- standing order

– Ketamine for disentanglement and maybe adjunctively

Oversight and safety for the patients

– Must be close review of usage

Oversight and safety for the providers

– Must be clear compliance with regulatory requirements

Conclusions

Develop a range of responses

Tailor the therapy for the anticipated procedure

Patient report of pain and subjective complaint drives

your care

Treat early and often, it requires less overall

If you have any questions, talk about it

Golden rule of pain management …

Pain is whatever the patient says it is…

Thank you.

daileym@mail.amc.edu