oh what a relief it is! pain management in ems laurie a. romig, md, facep medical director pinellas...
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Oh What a Relief It Is!Oh What a Relief It Is!
Pain Management in Pain Management in EMSEMS
Laurie A. Romig, MD, FACEPLaurie A. Romig, MD, FACEPMedical DirectorMedical Director
Pinellas County (FL ) EMSPinellas County (FL ) EMS
Pain Management in Pain Management in EMSEMS
Laurie A. Romig, MD, FACEPLaurie A. Romig, MD, FACEPMedical DirectorMedical Director
Pinellas County (FL ) EMSPinellas County (FL ) EMS
‘‘We must all die. But that I can save a person from days of torture,
that iswhat I feel is my great and ever-
new privilege. Pain is a more terrible lord of mankind than even
death itself.’’
-Albert Schweitzer
ObjectivesObjectives Provide a better understanding of how badly we and the rest of the medical profession handle pain Identify some of the barriers to better pain management for all patients Describe some common pharmacological pain interventions Describe some nonpharmacological pain interventions
Provide a better understanding of how badly we and the rest of the medical profession handle pain Identify some of the barriers to better pain management for all patients Describe some common pharmacological pain interventions Describe some nonpharmacological pain interventions
Survey says:Survey says:
Do you believe that prehospital pain management is a:
High priority and important goal Nice to do if you have the time, but not a priority Not at all important Not our job or our problem (nobody ever died of pain)
Do you believe that prehospital pain management is a:
High priority and important goal Nice to do if you have the time, but not a priority Not at all important Not our job or our problem (nobody ever died of pain)
Survey says:Survey says: How many of you have:
Protocols for pain meds before or without medical control contact Protocols for pain meds only after medical control contact IV opiates Intranasal opiates Other non-opiate analgesics such as ketorolac (Toradol) BLS measures only
How many of you have: Protocols for pain meds before or without medical control contact Protocols for pain meds only after medical control contact IV opiates Intranasal opiates Other non-opiate analgesics such as ketorolac (Toradol) BLS measures only
Survey says:Survey says:
How well do you think your service does with pain management?
We do great. Nobody suffers unnecessarily Pretty good, but we could do better Not very well What pain management?
How well do you think your service does with pain management?
We do great. Nobody suffers unnecessarily Pretty good, but we could do better Not very well What pain management?
Prevalence of PainPrevalence of Pain
Studies show that pain of some type is a presenting complaint for up to 70% of all ED patients
The percentage for EMS is probably similar.
One study showed that 20% of EMS patients complain of at least moderate to severe pain
Other studies show that all medical practitioners, including EMS are poor pain evaluators and managers
Studies show that pain of some type is a presenting complaint for up to 70% of all ED patients
The percentage for EMS is probably similar.
One study showed that 20% of EMS patients complain of at least moderate to severe pain
Other studies show that all medical practitioners, including EMS are poor pain evaluators and managers
JCAHO now recognizes pain evaluation as the “fifth vital sign” and judges hospitals on their pain management policies In many cases, pain relief is the primary expectation of our patients
JCAHO now recognizes pain evaluation as the “fifth vital sign” and judges hospitals on their pain management policies In many cases, pain relief is the primary expectation of our patients
In many cases, it is the ONLY thing that we can offer the patient other than transport to the hospital Pain management is often neglected or, at best, delayed in Emergency Departments
In many cases, it is the ONLY thing that we can offer the patient other than transport to the hospital Pain management is often neglected or, at best, delayed in Emergency Departments
EMS LiteratureEMS Literature
1073 patients with suspected extremity fractures
only 1.8% were administered analgesics
17% received ice packs25% received air splints
Akron Fire DepartmentPublished 2004
1073 patients with suspected extremity fractures
only 1.8% were administered analgesics
17% received ice packs25% received air splints
Akron Fire DepartmentPublished 2004
EMS LiteratureEMS Literature124 patients
with ED diagnosis of hip or lower extremity fractures18.3% were administered field
analgesics91% received analgesia in the ED
(ED patients - 2 Hour Delay)
William Beaumont Hospital, Royal Oak, MichiganPublished 2002
124 patientswith ED diagnosis of
hip or lower extremity fractures18.3% were administered field
analgesics91% received analgesia in the ED
(ED patients - 2 Hour Delay)
William Beaumont Hospital, Royal Oak, MichiganPublished 2002
EMS LiteratureEMS Literature
128 elderly patientswith field diagnosis
femoral neck fractures51% received field pain
managementOnly 2 patients received splints in the field
Westmead Hospital, Sydney, AustraliaPublished 2003
128 elderly patientswith field diagnosis
femoral neck fractures51% received field pain
managementOnly 2 patients received splints in the field
Westmead Hospital, Sydney, AustraliaPublished 2003
Why is oligoanalgesia so prevalent?Why is oligoanalgesia so prevalent?
Few EMS textbooks devote significant attention to pain management
EMS education on pain management lacking
Many EMS systems do not have pain management protocols
Few EMS textbooks devote significant attention to pain management
EMS education on pain management lacking
Many EMS systems do not have pain management protocols
Why is oligoanalgesia so prevalent?Why is oligoanalgesia so prevalent?
EMS personnel want to avoid conflict with ED physicians
ED physicians want to avoid conflict with surgical consultants
EMS personnel want to avoid conflict with ED physicians
ED physicians want to avoid conflict with surgical consultants
Myths About Pain ManagementMyths About Pain Management
Care providers can accurately assess a patient’s pain by observation Pain affects all people in the same way Everyone responds to analgesics in the same way Analgesia can create difficulty in assessing abdominal pain and other clinical conditions
Care providers can accurately assess a patient’s pain by observation Pain affects all people in the same way Everyone responds to analgesics in the same way Analgesia can create difficulty in assessing abdominal pain and other clinical conditions
Myths About Pain ManagementMyths About Pain Management
Patients become unable to give informed consent Use of narcotics in acute pain leads to increase in addiction Analgesic use in the field is unsafe
Patients become unable to give informed consent Use of narcotics in acute pain leads to increase in addiction Analgesic use in the field is unsafe
Myth: Care providers can accurately assess pain by observation
Myth: Care providers can accurately assess pain by observation
Self-reporting is actually shown to be the most accurate reflection of pain intensity, NOT the care provider’s opinion Care providers are influenced in their subjective evaluations by other patient factors and by their prior personal and professional experience with pain
Self-reporting is actually shown to be the most accurate reflection of pain intensity, NOT the care provider’s opinion Care providers are influenced in their subjective evaluations by other patient factors and by their prior personal and professional experience with pain
Myth: Pain affects all people in the same wayMyth: Pain affects all people in the same way
Pain perception is affected by: Age (KIDS DO HURT AND THEY DO REMEMBER IT!) Gender Race Culture Emotions Cognitive state Previous experience
Pain perception is affected by: Age (KIDS DO HURT AND THEY DO REMEMBER IT!) Gender Race Culture Emotions Cognitive state Previous experience
Pain AssessmentPain Assessment
Objective measures of pain ratings improve pain management
Help to balance imprecise clinician pain assessment Assist in tracking success of pain management Are available for both adult and pediatric ages, even down to neonates!
Objective measures of pain ratings improve pain management
Help to balance imprecise clinician pain assessment Assist in tracking success of pain management Are available for both adult and pediatric ages, even down to neonates!
Pain AssessmentPain Assessment
Numeric Rating Scale 0-10 0 = No pain 10 = The worst pain you can imagine Requires verbal and cognitive ability
Numeric Rating Scale 0-10 0 = No pain 10 = The worst pain you can imagine Requires verbal and cognitive ability
Pain AssessmentPain Assessment
Visual Analog Scale 10 cm line with left end being “no pain” and right end being “worst pain imaginable” Have patient mark their pain level on the line Pain level measured in millimeters Requires vision, cognition and relatively large amount of space to perform
Visual Analog Scale 10 cm line with left end being “no pain” and right end being “worst pain imaginable” Have patient mark their pain level on the line Pain level measured in millimeters Requires vision, cognition and relatively large amount of space to perform
Pain AssessmentPain Assessment
Verbal Rating Scale None, mild, moderate, severe, unbearable Requires cognitive ability
Verbal Rating Scale None, mild, moderate, severe, unbearable Requires cognitive ability
Pain AssessmentPain Assessment Wong-Baker FACES Scale
Works well for pediatrics Also works well for some adult patients unable to perform other scales
Wong-Baker FACES Scale Works well for pediatrics Also works well for some adult patients unable to perform other scales
Also comes in a 0 to 10 format
Myth: Everyone responds to analgesics the same wayMyth: Everyone responds to analgesics the same way
Many factors can affect how a given drug and dose will affect different people
Body weight Lean vs. total
Hemodynamic status Drug tolerance Metabolic rate Concurrent drug use
Many factors can affect how a given drug and dose will affect different people
Body weight Lean vs. total
Hemodynamic status Drug tolerance Metabolic rate Concurrent drug use
Myth: Analgesics can create difficulty in physical examination and diagnosis
Myth: Analgesics can create difficulty in physical examination and diagnosis
A number of studies have shown that early administration of analgesics
Allows patients to relax Removes voluntary guarding Permits better assessment of localized tenderness
A number of studies have shown that early administration of analgesics
Allows patients to relax Removes voluntary guarding Permits better assessment of localized tenderness
Myth: Analgesics can create difficulty in physical examination and diagnosis
Myth: Analgesics can create difficulty in physical examination and diagnosis
Administration of morphine to pediatric patients with abdominal pain did not affect the clinician’s ability to recognize children with surgical conditions
Published 2002
Administration of morphine to pediatric patients with abdominal pain did not affect the clinician’s ability to recognize children with surgical conditions
Published 2002
Myth: Analgesics can create difficulty in physical examination and diagnosis
Myth: Analgesics can create difficulty in physical examination and diagnosis
In a survey of emergency medicine physicians
ED physicians believe judicious use of pain medication does not compromise physical exam
BUT the majority withheld analgesics until after evaluation by the general surgeon
Published 2000
In a survey of emergency medicine physicians
ED physicians believe judicious use of pain medication does not compromise physical exam
BUT the majority withheld analgesics until after evaluation by the general surgeon
Published 2000
Myth: Patients become incapable of giving informed consent
Myth: Patients become incapable of giving informed consent
Multiple studies show that patients retain their ability to
give informed consent despite the effects of analgesics
Multiple studies show that patients retain their ability to
give informed consent despite the effects of analgesics
Myth: Use of narcotics in acute pain leads to an increase in addiction
Myth: Use of narcotics in acute pain leads to an increase in addiction
NO research supports this Assumption is often based on the fact that many people appear to become “drug-seekers” after an acute injury
In fact, these “drug-seekers” are often only the victims of inadequate pain management (oligoanalgesia) and a medical culture that does not recognize it’s own limited understanding of pain issues
NO research supports this Assumption is often based on the fact that many people appear to become “drug-seekers” after an acute injury
In fact, these “drug-seekers” are often only the victims of inadequate pain management (oligoanalgesia) and a medical culture that does not recognize it’s own limited understanding of pain issues
A note about “drug-seekers”A note about “drug-seekers”
Check with your medical director about his or her philosophy In general, EMS should NOT be attempting to determine if a patient is a drug-seeker
Especially without an on-going familiarity with the patient Doing so may cause you to unfairly under-treat patients
Check with your medical director about his or her philosophy In general, EMS should NOT be attempting to determine if a patient is a drug-seeker
Especially without an on-going familiarity with the patient Doing so may cause you to unfairly under-treat patients
Myth: Analgesics are UnsafeMyth: Analgesics are Unsafe
One study evaluated 84 cases using small doses (2-4 mg) of morphine
Only one case of MS induced respiratory depression was found
Published 1992
One study evaluated 84 cases using small doses (2-4 mg) of morphine
Only one case of MS induced respiratory depression was found
Published 1992
Myth: Analgesics are UnsafeMyth: Analgesics are Unsafe
Another study reviewed 131 air-transported patientswho received fentanyl.
There were no untoward events
Published 1998
Myth: Analgesics are UnsafeMyth: Analgesics are Unsafe
2129 patients administered fentanyl in the field
12 patients (0.6%) had a VS abnormalitydue to fentanyl administration
Only 1 patient required a recovery intervention
Published 2005
Remember that any analgesic (and most EMS drugs) CAN be unsafe in
the field if used outside of reasonable protocols and
standard of care boundaries and without
appropriate quality management.
Let’s take a break!Let’s take a break!
Safe Use of AnalgesicsSafe Use of Analgesics Understand the concepts of time of onset of action and peak effect (pharmacodynamics) and the values for each drug you use
Giving additional doses of medication prior to a previous dose taking effect puts you at risk for creating a problem for the patient
Understand the concepts of time of onset of action and peak effect (pharmacodynamics) and the values for each drug you use
Giving additional doses of medication prior to a previous dose taking effect puts you at risk for creating a problem for the patient
Safe Use of AnalgesicsSafe Use of Analgesics
Slow and steady is better than hard and fast
Titrate small doses at appropriate intervals
Slow and steady is better than hard and fast
Titrate small doses at appropriate intervals
Safe Use of AnalgesicsSafe Use of Analgesics
Beware the effects of combining drugs
Particularly when added to not taking pharmacodynamics into account, adding one CNS depressant or hemodynamic depressant drug to another can create unpredictable changes
Beware the effects of combining drugs
Particularly when added to not taking pharmacodynamics into account, adding one CNS depressant or hemodynamic depressant drug to another can create unpredictable changes
Safe Use of AnalgesicsSafe Use of Analgesics
Don’t forget to ask about medication allergies, current medications and when they were last taken
Remember to look for Fentanyl patches!! Adding IV opiates on top of recently taken oral sedatives, analgesics or muscle relaxants may cause unpredictable additive effects as well
Don’t forget to ask about medication allergies, current medications and when they were last taken
Remember to look for Fentanyl patches!! Adding IV opiates on top of recently taken oral sedatives, analgesics or muscle relaxants may cause unpredictable additive effects as well
Safe Use of AnalgesicsSafe Use of Analgesics
Know your pain management goal Does your pain management protocol have a goal?
”Make the ride more bearable”? “Decrease pain by 50%”? “Decrease pain to “x” or less”? “Make patient painfree”?
Your goal may actually be different for different types of patients
Know your pain management goal Does your pain management protocol have a goal?
”Make the ride more bearable”? “Decrease pain by 50%”? “Decrease pain to “x” or less”? “Make patient painfree”?
Your goal may actually be different for different types of patients
Safe Use of AnalgesicsSafe Use of Analgesics
Reassess the patient (including pain scale) frequently Document carefully (including pain scale) Take the patient’s hemodynamic state into account if your medication may affect it
Reassess the patient (including pain scale) frequently Document carefully (including pain scale) Take the patient’s hemodynamic state into account if your medication may affect it
Safe Use of AnalgesicsSafe Use of Analgesics
Always give complete report to ED staff regarding drugs given, time given, and results or adverse reactions
It can be difficult to sort out whether changes in level of consciousness or development of respiratory or circulatory compromise are due to the drug or to underlying illness or injury without good info on timing and sequence
Always give complete report to ED staff regarding drugs given, time given, and results or adverse reactions
It can be difficult to sort out whether changes in level of consciousness or development of respiratory or circulatory compromise are due to the drug or to underlying illness or injury without good info on timing and sequence
Who should receive analgesics?Who should receive analgesics?
As always, go by your own protocol Your local protocol may depend upon your medical director’s attitudes and experience with pain management and/or your medical community’s
As always, go by your own protocol Your local protocol may depend upon your medical director’s attitudes and experience with pain management and/or your medical community’s
Who should receive analgesics?Who should receive analgesics?
Your protocol may (and should) address
Abdominal pain patients Pediatric/infant patients Headache patients Trauma patients (particularly multiple blunt trauma) Hemodynamically unstable patients The elderly Short transport time patients
Your protocol may (and should) address
Abdominal pain patients Pediatric/infant patients Headache patients Trauma patients (particularly multiple blunt trauma) Hemodynamically unstable patients The elderly Short transport time patients
Who should receive analgesics?Who should receive analgesics?
Your protocol MAY contain minimum pain level requirements or specifications for acute versus chronic pain
ED docs may complain about what they perceive of as “minor” patients receiving IV analgesics They may also complain about chronic or subacute pain patients receiving IV analgesics
Your protocol MAY contain minimum pain level requirements or specifications for acute versus chronic pain
ED docs may complain about what they perceive of as “minor” patients receiving IV analgesics They may also complain about chronic or subacute pain patients receiving IV analgesics
Who should receive analgesics?Who should receive analgesics?
Remember that nonpharmacological pain management methods are usually safe and can be surprisingly effective
Ice or heat Elevation Splinting/positioning Emotional support Distraction (guided imagery, biofeedback, breathing exercises)
Remember that nonpharmacological pain management methods are usually safe and can be surprisingly effective
Ice or heat Elevation Splinting/positioning Emotional support Distraction (guided imagery, biofeedback, breathing exercises)
Common Prehospital AnalgesicsCommon Prehospital Analgesics
How do I choose?How do I choose?
Desirable characteristics for EMS analgesic
Quick acting (short onset and peak effect) Short duration Minimize side effects
Hypotension, respiratory suppression, emesis, etc.
Easy to administer Multiple administration routes available Reversible Inexpensive
Desirable characteristics for EMS analgesic
Quick acting (short onset and peak effect) Short duration Minimize side effects
Hypotension, respiratory suppression, emesis, etc.
Easy to administer Multiple administration routes available Reversible Inexpensive
How do I choose?How do I choose?
Take patient allergies into consideration Take patient condition into consideration
Use the least hemodynamically active agent if patient is unstable
Sometimes it’s a crap shoot! Individual patients may react better to some drugs than to others, but usually it’s still just a matter of giving ENOUGH drug
Take patient allergies into consideration Take patient condition into consideration
Use the least hemodynamically active agent if patient is unstable
Sometimes it’s a crap shoot! Individual patients may react better to some drugs than to others, but usually it’s still just a matter of giving ENOUGH drug
My Favorite…My Favorite…
Fentanyl
Fentanyl (Sublimaze)Fentanyl (Sublimaze)
An opiate with sedative and analgesic properties Used in OR’s for many years, has become much more common in ED’s and EMS in last 5 years or so May be used IV, IM, intranasal, transmucosal, and transdermal May be used safely for both adults and children
An opiate with sedative and analgesic properties Used in OR’s for many years, has become much more common in ED’s and EMS in last 5 years or so May be used IV, IM, intranasal, transmucosal, and transdermal May be used safely for both adults and children
FentanylFentanyl May be used for pain management (including cardiac ischemia), sedation, and as part of facilitated intubation and/or rapid sequence intubation Reversible with Narcan Causes less emesis than Morphine Inexpensive No cross-reactivity in morphine allergic patients 100 x as potent as morphine
May be used for pain management (including cardiac ischemia), sedation, and as part of facilitated intubation and/or rapid sequence intubation Reversible with Narcan Causes less emesis than Morphine Inexpensive No cross-reactivity in morphine allergic patients 100 x as potent as morphine
FentanylFentanyl Generally minimal effect on blood pressure, heart rate and ventilatory drive Helps to blunt HR and BP associated with intubation Chest wall rigidity or muscle twitching can occur
Should be reversible with Narcan
Most side effects result from pushing the medication too quickly
Generally minimal effect on blood pressure, heart rate and ventilatory drive Helps to blunt HR and BP associated with intubation Chest wall rigidity or muscle twitching can occur
Should be reversible with Narcan
Most side effects result from pushing the medication too quickly
FentanylFentanyl Onset of action
IV: 1-2 minutes IM and IN: 7-15 minutes
Peak effect IV: several minutes IM and IN: 15 minutes
Duration of effect IV: 30-60 minutes IM (and IN?): 60-120 minutes
Onset of action IV: 1-2 minutes IM and IN: 7-15 minutes
Peak effect IV: several minutes IM and IN: 15 minutes
Duration of effect IV: 30-60 minutes IM (and IN?): 60-120 minutes
FentanylFentanyl Dosing for pain management
1-2 mcg/kg IV over at least one minute q 1-3 minutes for hemodynamically stable peds and non-elderly adults
Some services deliver in 50 mcg increments rather than by weight
Recommend starting with 0.5 mcg/kg for elderly and hemodynamically unstable patients
Dosing for pain management 1-2 mcg/kg IV over at least one minute q 1-3 minutes for hemodynamically stable peds and non-elderly adults
Some services deliver in 50 mcg increments rather than by weight
Recommend starting with 0.5 mcg/kg for elderly and hemodynamically unstable patientsNote: For all opiates, reduce doses if using
another CNS depressant concurrently.
FentanylFentanyl
Dosing for pain management IM dose: Few recommendations in literature. Would start with IV dose but remember that it will take MUCH longer to have initial and peak effect IN dose: Depends on concentration you have available.
Dr. Tim Wolfe recommends 1.5 mcg/kg per dose, but can only administer max of 1 cc of fluid per nostril
Dosing for pain management IM dose: Few recommendations in literature. Would start with IV dose but remember that it will take MUCH longer to have initial and peak effect IN dose: Depends on concentration you have available.
Dr. Tim Wolfe recommends 1.5 mcg/kg per dose, but can only administer max of 1 cc of fluid per nostril
FentanylFentanyl
Dosing for sedation Light, anxiolytic sedation: 1 mcg/kg IV Deep sedation for procedures: 2-3 mcg/kg IV (fentanyl alone) or 1-2 mcg/kg IV (fentanyl with another agent) Once you get above 3-4 mcg/kg you’re looking at general anesthesia level doses!
Dosing for sedation Light, anxiolytic sedation: 1 mcg/kg IV Deep sedation for procedures: 2-3 mcg/kg IV (fentanyl alone) or 1-2 mcg/kg IV (fentanyl with another agent) Once you get above 3-4 mcg/kg you’re looking at general anesthesia level doses!
MorphineMorphine
An opiate with sedative and analgesic properties Still considered by many to be “The Gold Standard” May be used IV, IM, SC or orally May be used safely for adults and pediatrics
An opiate with sedative and analgesic properties Still considered by many to be “The Gold Standard” May be used IV, IM, SC or orally May be used safely for adults and pediatrics
MorphineMorphine
Reversible with Narcan More likely to cause emesis than Fentanyl Inexpensive Opioid potency is compared to 10 mg of morphine IV
10 mg morphine IV equivalent to 100 mcg (0.1 mg) of fentanyl IV
Reversible with Narcan More likely to cause emesis than Fentanyl Inexpensive Opioid potency is compared to 10 mg of morphine IV
10 mg morphine IV equivalent to 100 mcg (0.1 mg) of fentanyl IV
MorphineMorphine
More likely to cause respiratory depression, hypotension, bronchospasm and tachycardia than fentanyl
due to histamine release
May actually increase intracranial pressure
More likely to cause respiratory depression, hypotension, bronchospasm and tachycardia than fentanyl
due to histamine release
May actually increase intracranial pressure
MorphineMorphine Onset of action
IV: 5-20 minutes (longer than fentanyl) IM: ?
Peak effect IV: 30 minutes (longer than fentanyl) IM: ?
Duration of action IV: 2-3 hours (longer than fentanyl) IM: 3-5 hours
Onset of action IV: 5-20 minutes (longer than fentanyl) IM: ?
Peak effect IV: 30 minutes (longer than fentanyl) IM: ?
Duration of action IV: 2-3 hours (longer than fentanyl) IM: 3-5 hours
MorphineMorphine
Dosing for pain management 0.05-0.3 mg/kg IV Many protocols call for increments of 2-4 mg IV titrated for adults, others for doses of 5-10 mg IV May be wise to do a “test dose” of 1-2 mg to gauge hemodynamic effect Typical pediatric dose is 0.1 mg/kg IV Typical IM dose for adult is 5-10 mg
Dosing for pain management 0.05-0.3 mg/kg IV Many protocols call for increments of 2-4 mg IV titrated for adults, others for doses of 5-10 mg IV May be wise to do a “test dose” of 1-2 mg to gauge hemodynamic effect Typical pediatric dose is 0.1 mg/kg IV Typical IM dose for adult is 5-10 mg
Nitrous OxideNitrous Oxide
Inhalation agent with analgesic and anesthetic properties In use for many years Usually 50/50% mix with oxygen Onset and duration of action: 3-5 minutes Can be self-administered
Inhalation agent with analgesic and anesthetic properties In use for many years Usually 50/50% mix with oxygen Onset and duration of action: 3-5 minutes Can be self-administered
Nitrous OxideNitrous Oxide Do not secure mask to the patient’s face
Mask will fall away if patient becomes oversedated Effects rapidly wear off
Side effects mostly nausea/vomiting Contraindicated for suspected pneumothorax, possible bowel obstruction and other situations where gas may be entrapped in a closed space of the body
Do not secure mask to the patient’s face
Mask will fall away if patient becomes oversedated Effects rapidly wear off
Side effects mostly nausea/vomiting Contraindicated for suspected pneumothorax, possible bowel obstruction and other situations where gas may be entrapped in a closed space of the body
Nitrous OxideNitrous Oxide
Discontinued in some EMS systems because of abuse problems Potential for gas to enter the ambient atmosphere and affect EMS providers
Discontinued in some EMS systems because of abuse problems Potential for gas to enter the ambient atmosphere and affect EMS providers
Butorphanol (Stadol)Butorphanol (Stadol)
Opiate agonist-antagonist Because of this, Stadol is thought to create less respiratory depression and less risk of drug dependence with chronic use May be used IV, IM or IN Can cause withdrawal symptoms if used in patients who are narcotic dependent May also cause need for increased doses of other narcotics for subsequent pain management and/or anesthesia
Opiate agonist-antagonist Because of this, Stadol is thought to create less respiratory depression and less risk of drug dependence with chronic use May be used IV, IM or IN Can cause withdrawal symptoms if used in patients who are narcotic dependent May also cause need for increased doses of other narcotics for subsequent pain management and/or anesthesia
Butorphanol (Stadol)Butorphanol (Stadol)
Relatively unpredictable effectiveness Nalbuphine (Nubain) is similar drug Both are considered less than ideal prehospital drugs
Relatively unpredictable effectiveness Nalbuphine (Nubain) is similar drug Both are considered less than ideal prehospital drugs
Butorphanol (Stadol)Butorphanol (Stadol)
Onset of action IV: 1 minute IM/IN: 15 minutes
Peak effect IV: 4-5 minutes IM: 30-60 minutes IN: ?
Onset of action IV: 1 minute IM/IN: 15 minutes
Peak effect IV: 4-5 minutes IM: 30-60 minutes IN: ?
Butorphanol (Stadol)Butorphanol (Stadol)
Duration of action IV: 2-4 hours IM: 3-4 hours IN: ?
Stadol dosing IV/IM: 2-4 mg IN: 1-2 mg
Duration of action IV: 2-4 hours IM: 3-4 hours IN: ?
Stadol dosing IV/IM: 2-4 mg IN: 1-2 mg
Ketorolac (Toradol)Ketorolac (Toradol)
Nonsteroidal anti-inflammatory agent Can be administered IV or IM Expensive Effective in disorders such as kidney stones and musculoskeletal disorders but is NOT better than opiates in either Dose 30 mg IV or 60 mg IM
Nonsteroidal anti-inflammatory agent Can be administered IV or IM Expensive Effective in disorders such as kidney stones and musculoskeletal disorders but is NOT better than opiates in either Dose 30 mg IV or 60 mg IM
Ketorolac (Toradol)Ketorolac (Toradol)
Few obvious acute side effects (such as hypotension, respiratory depression, emesis) BUT Potentially significant hidden side effects
Platelet inhibitor activity can worsen bleeding for up to a week after single injection Renal toxicity (especially in elderly)
Few obvious acute side effects (such as hypotension, respiratory depression, emesis) BUT Potentially significant hidden side effects
Platelet inhibitor activity can worsen bleeding for up to a week after single injection Renal toxicity (especially in elderly)
Before we finish…Before we finish…You can download this Powerpoint from
www.jumpstarttriage.com
Go to the The Other Dr. Romig page from the home page and click on the
appropriate link at the bottom of the page
You’re also welcome to any of the other lectures listed. I just ask that appropriate attributions are made if you use them for presentation or research purposes. Please
contact me with any questions or corrections.
SummarySummary
Pain management can and should be a major intervention for prehospital providers There are a number of myths regarding pain management that are being factually debunked
But not all healthcare providers are aware or convinced
Pain management can and should be a major intervention for prehospital providers There are a number of myths regarding pain management that are being factually debunked
But not all healthcare providers are aware or convinced
SummarySummary
Prehospital pain management CAN be performed safely when appropriate drug choices, protocols, education, documentation and quality management tools are integrated What would you want if YOU or a loved one were the patient in pain?
Prehospital pain management CAN be performed safely when appropriate drug choices, protocols, education, documentation and quality management tools are integrated What would you want if YOU or a loved one were the patient in pain?
