16Problems Pain appears to be under treated: Failure to assess pain. Failure to quantify pain.Fear of addiction.Legal constraints of utilizing controlled substances.Ignorance
17Problems UCLA Medical Center Study: Hispanic patients with isolated long-bone fractures were twice as likely to receive NO pain medication when compared to their non-Hispanic white counterparts.Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(10):1537-9
18Problems Grady Memorial Hospital: Black patients with isolated long-bone fractures were less likely to receive adequate analgesia when compared to their white counterparts.Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16
19Problems Nationwide survey of burn patients: Only half of burn patients treated in emergency departments received adequate analgesia for their burn pain.Singer AJ, Thode HC Jr. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehabil. 2002;23(6):361-5
20Problems EMS Study (Pediatrics) Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia.Swor R, McEachin CM, Sequin D. Grall KH. Prehospital pain management in children suffering traumatic injury. Prehospital Emergency Care. 2005;9(1):40-43
22Prehospital Pain Management Pain in the prehospital setting is often:Not identified,Under treated,Both.Ricard-Hibon A, Leroy N, Magne M, et al. Evaluation of acute pain in prehospital medicine. Ann Fr Anesth Reanim. 1997;16(8):945-9
23Prehospital Pain Management Patients with extremity fractures receive inadequate analgesia.Study of 1,073 patients found only 1.5% received analgesia in the prehospital setting.White LJ, Cooper LJ, Chambers RM, Gradisek RE. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care. 2000;4(3):205-8
24Prehospital Pain Management Prehospital patients with lower-extremity fractures (including hip fractures):Only 18.3% of eligible patients received analgesia.McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care. 2002;6(4):
25Prehospital Pain Management Femoral neck fractures are among the most common orthopedic injuries encountered in prehospital care.
26Prehospital Pain Management Hip fractures:Only a modest proportion of these patients receive prehospital analgesia for this painful and debilitating injury.Vassiliadis J, Hitos K, Hill CT. Factors influencing prehospital and emergency department analgesia administration to patients with femoral neck fractures. Emerg Med (Fremantle) :14(3):261-6
27Prehospital Pain Management Nothing is more cruel than:Retrieving elderly patient with isolated hip fracture.Tying them to a sheet of plywood or plastic.Wrapping a hard collar around their arthritic neck.Placing them in a 2-ton truck.Driving them to the hospital over rough roads.
28Prehospital Pain Management Without adequate analgesia!
29What is Pain? A sensory or emotional experience or discomfort. Single, most common medical complaint.
30Qualities of Pain Organic versus Psychogenic Acute versus Chronic Malignant versus BenignContinuous versus Episodic
31Types of Pain Acute pain: Chronic pain: Pain associate with an acute eventChronic pain:Pain that persists after an acute event is overPain that last 6 months or more
33PathophysiologyThe generation of pain involves interaction between all parts of the nervous system.
34PathophysiologySignificant strides have been made as to how the body senses and interprets pain over the last 2 decades.Pain-generation pathways more clearly understood.Chronic pain better understood.
35PathophysiologyPain is more than a just a feeling or sensation, but linked to the complex psychosocial factors that surround traumatic events.Pain is the brain’s interpretation of the painful stimulus.
36Pathophysiology Perceiving pain: Algogenic substances—chemicals released at the site of injury.Nociceptors—Afferent neurons that carry pain messages.Referred pain—pain that is perceived as if it were coming from somewhere else in the body.
37Pathophysiology Nociception Derived from the word noxious meaning harmful or damaging to the tissues.Mechanical event that occurs in tissues undergoing cellular injury.
38PathophysiologyNociceptive stimulus is detected by free nerve endings in the tissues.Three type of stimuli excite pain receptors:MechanicalThermalChemical
40PathophysiologyPain fibers principally located in the superficial layers of the skin.Pain fibers also located in:PeriosteumArterial wallsJoint surfacesFalx and tentorium of the cranial vault.
41Pathophysiology Deep structures: Sparsely supplied with pain fibers Widespread tissue damage still causes the slow, chronic, aching-type pain.
42Pathophysiology Visceral Pain: Ischemia Chemical stimuli Spasm of hollow viscusOver distension of a hollow viscous
43Pathophysiology Chemicals that excite pain receptors: Bradykinin SerotoninHistaminePotassium ionsAcidsAcetylcholineProteolytic enzymes
44PathophysiologyChemicals that enhance the sensitivity of pain endings, but do not necessarily excite them:ProstaglandinsSubstance P
45Pathophysiology Types of pain: Fast Pain: Felt within 0.1 second after painful stimulusAlso called: sharp pain, pricking pain, electric pain and acute pain.Felt with needle stick, laceration, burn
46Pathophysiology Types of pain: Slow Pain: Felt within 1.0 second or more after painful stimulusAlso called: dull pain, aching pain, throbbing pain and chronic pain.Usually associated with tissue destruction
47PathophysiologyPain fibers transmit impulse to spinal cord through fast or slow fibers:A-δ (delta) fibers—small myelinated fibers that transmit sharp pain.C fibers—small unmyelinated fibers that transmit dull pain or aching pain.
48PathophysiologyPain is often a “double” sensation as fast pain is transmitted by the Aδ fibers while a second or so later it is transmitted by the C fiber pathway.
49PathophysiologyPain impulses enter the spinal cord from the dorsal spinal nerve roots.Fibers terminate on neurons in the dorsal horns.
87Pain Management NSAIDs Effective for pain and inflammation Good side-effect profileSecond generation NSAIDs have better side-effect profilesInhibit prostaglandins and other mediators of pain and inflammation
88Ketorolac (Toradol) Only injectable NSAID in the US Analgesic, antipyretic and anti-inflammatory properties.
89Ketorolac (Toradol) Used for moderate-severe pain Orthopedic and soft-tissue injuriesPopular for ureteral colic.Often used in conjunction with centrally-acting agents such as morphine.
90Ketorolac (Toradol) Onset of action: < 30 minutes IV Peak effects: minutesDuration: 4-6 hoursTypical IV dose: 30 mg
91Pain Management Centrally-acting agents: Opiates Anesthetic gasses used in analgesic quantitiesAtypical agents (ketamine)
92Opiates Mainstay of analgesic practice Originally derived from the opium poppy plantMany now synthetically manufactured
110Fentanyl Synthetic opiate—chemically unrelated to morphine Initially an anesthetic induction agentShort-actingPharmacological effects similar to that of morphineBetter side-effect profile because of short duration of action.
111Fentanyl Less histamine release than morphine Sivilotti ML, Ducharme J. Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study. Ann Emerg Med. 1998;31(3):125-6.
112FentanylNow routinely used in emergency medicine and, to a lesser degree, in EMSChudnofsky CR, Wright SW, Dronen SC, et al. The safety of fentanyl in the emergency department. Ann Emerg Med. 1989;18(6):
113FentanylUsed in multiple trauma patients because of hemodynamic profile.Walsh M, Smith GA, Yount RA, et al. Continuous intravenous infusion for sedation and analgesia of the multiple trauma patient. Ann Emerg Med. 1991;20(8):913-5.
114FentanylProven effective in the prehospital (air medical) treatment of pediatric trauma patients.No untoward effects during 5 years of prehospital useDevellis P, Thomas SH, Wedel SK, et al. Prehospital fentanyl analgesia in air-transported pediatric trauma patients. Pediatr Emerg Care. 1998;14(5):321-3.
115Fentanyl Onset of action: Immediate IV Peak effects: 3-5 minutes Duration: minutesTypical IV dose: μgs
117Synthetic Mixed Opiates Sub-class of opiates with both agonistic and antagonistic propertyActivate some opiate receptors while blocking othersReportedly decreases the likelihood of abuse and respiratory depressionNot controlled in many states
119Nalbuphine Most common mixed agent used in prehospital care Antagonistic properties decrease the potential for abuse.
120NalbuphineInitial studies indicated it was an effective alternative to morphine.Chambers JA, Guly HR. Prehospital intravenous nalbuphine administered by paramedics. Resuscitation. 1994;Stene JK, Stofberg L, MacDonald G, et al. Nalbuphine analgesia in the prehospital setting. Am J Emerg Med. 1988;6(6):634-9.
121NalbuphineSubsequent studies seem to suggest not as effective as once thought.English study found it offered poor pain control to a high proportion of patients in the prehospital setting.Wollard M, Jones T, Vetter N. Hitting them where it hurts? Low dose nalbuphine therapy. Emerg Med J 2002;19:
122NalbuphineBecause of antagonistic properties, prehospital nalbuphine usage appears to be responsible for increased opiate requirements once patients arrive in the ED.Houlihan KPG, Mitchell RG, Flapan AD, et al. Excessive morphine requirements after prehospital nalbuphine analgesia. J Accid Emerg Med 1999;16:29-31
123NalbuphineAlso appears to interfere with general anesthesia and maintenance.Robinson N, Burrow N. Excessive morphine requirements after pre-hospital nalbuphine analgesia. J Accid Emerg Med. 1999;16:123-7.
124NalbuphineProbably should have a limited role in emergency medicine and EMS.
125Nalbuphine Onset of action: 2-3 minutes IV Peak effects: < 30 minutesDuration of effect: 3-6 hoursTypical IV dose: 5-20 mg
127Butorphanol Used by a few EMS systems Similar properties to nalbuphine Role in EMS has not been widely studiedProbably should have a limited role in EMS
128Butorphanol Thought to be non-addictive. Stadol NS resulted in significant addictions
129Butorphanol Onset of action: < 1 minute IV Peak effects: 3-5 minutesDuration: 2-4 hoursTypical IV dose: mg
130Gasses Nitrous Oxide (N2O): Anesthetic at high concentrations Analgesic at low concentrationsInitially used in dentistry and obstetricsIntroduced into EMS in the 1970s.Effective in treating virtually all types of pain.
131Nitrous OxideSupplied as two-cylinder device (Nitronox) that feeds gases into a blender at 50:50 concentrationSelf-administered through modified demand valve.
132Nitrous OxideProven effective in numerous types of pain encountered in the prehospital setting.Stewart RD, Paris PM, Stoy WA, Cannon G. Patient-controlled inhalation analgesia in prehospital care: a study of side-effects and feasibility. Crit Care Med. 1983;11(11):851-5.Pons PT. Nitrous oxide analgesia. Emerg Med Clin North Am. 1988;6(4):777-82,
133Nitrous OxideEffective for painful procedures such as transcutaneous pacing.Kaplan RM, Heller MB, McPherson J, Paris PM. An evaluation of nitrous oxide analgesia during transcutaneous pacing. Prehosp Disaster Med. 1990;5(2):145-9.
134Nitrous OxideNAEMSP has issued a detailed position statement regarding it’s use.National Association of EMS Physicians. Use of nitrous oxide:oxygen mixtures in prehospital emergency care. Prehosp Disaster Med. 1990;5(3):273-4.
135Nitrous Oxide Probably underutilized for several reasons: Cost Bulky delivery systemStorage issuesLack of understanding regarding efficacy
137Myths of Pain Management MYTH #1: If I give my patient narcotics, they will not be competent enough to consent for surgery later.
138Myths of Pain Management Myth # 1: FALSEConcern about rendering patient incompetent is unfounded.Withholding analgesia can be looked upon as a form of “coercion” to sign consent for surgery.Gabbay DS, Dickenson ET. Refusal of base station physicians to authorize narcotic analgesia. Prehosp Emerg Care. 2001;3(5):293-5.
139Myths of Pain Management MYTH #2: If I give my patient narcotics for abdominal pain, it will change the physical examination findings, making diagnosis difficult.
140Myths of Pain Management Myth # 2: FalseThe dogma of withholding analgesia for fear that it will alter an abdominal examination stems from the 1921 book by Dr. Zachary Cope entitled Early Diagnosis of the Acute Abdomen that stated, “If morphine be given, it is possible for a patient to die happy in the belief that he is on the road to recovery, and in some cases the medical attendant may for a time be induced to share the elusive hope.”
141Myths of Pain Management Myth # 2: FalseSeveral researchers have examined this question:Patients with abdominal pain randomly assigned to receive either IV morphine or saline.Patients were assessed before and after the morphine or saline was administered, and then assessed later by a surgeon if indicated.The presence of peritoneal signs did not change in the group that received morphine and the accuracy of diagnosis did not differ between the two groups of patients as well as between the emergency physicians and the surgeons.In fact, there was also a trend that the examination may be more reliable after treatment with morphine.Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad. Emerg. Med. 1996;3:1086–1092
142Myths of Pain Management Myth # 2: False108 children with abdominal pain.52 morphine56 placebo (saline)Groups well matched.Morphine effectively reduces the intensity of [ain and does not seem to impede the diagnosis of appendicitis.Green R. et al. Early analgesia for children with acute abdominal pain. Pediatrics. 2005;116:
143Myths of Pain Management MYTH #3: If I give my patient narcotics, they will develop respiratory arrest.
144Myths of Pain Management Myth # 3: FalseRespiratory depressant effects often offset by sympathetic stimulation in the pain patient.Different than from respiratory depression in pain-free opiate addicts.Key is to use correct analgesic dose
145Myths of Pain Management MYTH #4: If I give my patient narcotics, they will abuse narcotics
146Myths of Pain Management Myth # 4: FalseBecause a few patients malinger and drug-seek is no reason to withhold from legitimate pain patients.Addicts need analgesia on occasion too.Most people who become addicted to pain killers have underlying addictive tendencies.
147Myths of Pain Management Myth # 4: FalseIn a 5-year review, the medical use of opiates increased while the incidence of opiate abuse actually decreased.Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283(13):
155Methoxyflurane3 mL of methoxyflurane are placed onto the wick of the inhalerDevice gently shaken and any excess wiped offInhaler given to patient to self administerSupplemental oxygen can be provided.
156Methoxyflurane Pain relief usually begins in 8-10 breaths Lasts for minutesAllows time for IV access and morphineShould be used in well ventilated area.
157Methoxyflurane Why don’t we have it? Methoxyflurane limited to animal use in US.Reported liver and kidney toxicity (in anesthetic doses—not analgesic doses)US manufacturer quit making MetofaneCommonwealth of Australia considers the drug safe for analgesic usage
158Intranasal FentanylAustralian study has shown intranasal fentanyl safe and effective in treating trauma pain in children between 3-12 years of age.Children 3-7: 20 μg INChildren 8-12: 40 μg INAdditional 20 μg doses q 5 minutes
159Intranasal FentanylAllowed for early and significant reduction in pain.Shows great promise for emergency medicine and EMSBorland ML, Jacobs I, Geelhoed G. Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study. Emerg Med (Fremantle). 2002;14(3):275-80
160Alfentanil (Alfenta) Chemical analogue of fentanyl (shorter acting) Less side-effects than morphine
161Alfentanil (Alfenta)Faster, more effective pain relief when compared to morphine.No hemodynamic or respiratory side-effects occurred.Silfvast T, Saarnivaara. Comparison of alfentanil and morphine in the prehospital treatment of patients with acute ischaemic-type chest pain. Eur J Emerg Med. 2001;8(4):275-8.
162Tramadol Synthetic analogue of codeine. Has weak opioid agonistic properties.Slight abuse potentialNon-controlled
163Tramadol Parenteral form not yet available in US 1/10 as potent as morphineOnset of action: 1-5 minutes IVPeak effects: minutesDuration: 4.5 hoursTypical IV dose: 100 mg
164Tramadol Analgesia and side-effects similar to morphine. Concluded tramadol is an effective alternative to morphine in the prehospital setting.Vergnion M, Desgesves S, Garcey L, Magotteaux V. Tramadol, an Alternative to Morphine for Treating Posttraumatic Pain in the Prehospital Situation. Anest Analg. 2001;92:
165Entonox Single-cylinder pre-mixed 50:50 nitrous oxide oxygen mixture. Available everywhere but the US.Gasses tend to separate ~ 26° F (but remix with inversion of cylinder)Cheaper, less bulky,
167Entonox Study compared 2-cylinder to 1-cylinder system. Nitronox safer in cold weatherNo significant clinical differences overallMcKinnon KD. Prehospital analgesia with nitrous oxide/oxygen. Can Med Assoc J. 1981;125:
168EntonoxEntonox preferred over Nitronox by prehospital personnel involved in study.
169Non-PharmacologicalInteresting Austrian study for victims of minor trauma using acupressure.Patients randomly assigned to receive acupressure at “true points,” at “sham points” or “no acupressure.”Different values measured before and after treatment.
170AcupressureAt the end of transport, patients who received acupressure at “true points” had less pain, less anxiety, a slower heart rate, and greater satisfaction with the care provided.They concluded that acupressure is an effective and easy-to-learn treatment of pain in prehospital care.Kober A, ScheckT, Greher M et al. Prehospital analgesia with acupressure in victims of minor trauma: a prospective, randomized, double-blinded trial. Anest Analg. 2002;95(3):723-7.
171Summary How can we improve prehospital pain control? All personnel should assess for the presence and severity of pain.Use objective pain measuresMedical directors need to become more aggressive in pain management
172SummaryMove prehospital pain management decisions for most conditions from on-line medical control to standing orders.Time to morphine administration decreased by 2.3 minutes when this change made.Fullerton-Gleason L, Crandall C, Sklar DP. Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication. Prehosp Emerg Care. 2002;6(4):411-6
173SummaryLiberalization of prehospital pain protocols resulted in increased usage with no apparent safety or misuse issues.Pointer JA, Harlan K. Impact of liberalization of protocols for the use of morphine sulfate in an urban EMS system. Prehospital Emergency Care. 2005;9(4):
174SummaryField personnel, EMS physicians, administrators, and representatives from receiving hospitals should organize a comprehensive plan to assure that we are providing adequate analgesia in the prehospital setting.EMS is a compassionate profession and compassion begins with the relief of pain and suffering