Why Dont We Do a Better Job of Treating Pain

1
Why Dont We Do a Better Job of Treating Pain?

• Bryan E. Bledsoe, DO, FACEP
• Midlothian, TX

2
Introduction

• Many, if not most, medical conditions cause pain.

3
Introduction

• Pain is a protective mechanism and occurs
  whenever any tissues of the body are being
  damaged.

4
Introduction

• Pain occurs whenever the cells or tissues are
  being damagedwhatever the underlying cause.

5
Introduction

• The reaction to pain may be rapid, as seen when
  one touches a hot pan.

6
Introduction

• Or slow, as when one has been seated in the same
  position for an extended period of time.

7
Introduction

• It is for this reason that persons with spinal
  cord injuries are at risk for developing
  decubitus ulcers.

8
Introduction

• Because of their injury, they
• Cannot sense pain from the pressure area.
• Cannot move to eliminate the pressure.
• Or a combination of both.

9
Introduction

• One of the oldest roles of medical practitioners
  is to help alleviate pain.

10
Introduction

• Analgesia
• The relief of pain without a loss of
  consciousness.

11
Introduction

• Analgesia can be provided by
• Drugs
• Surgical Procedures
• Physical Modalities
• Other

12
Introduction

• Analgesia
• Eliminate the source of the pain.
• Block or attenuate the pathways that transmit
  pain impulses to the brain.
• Combination of the two.

13
Introduction

• Pain elicits a strong emotional response that is
  often recorded in our memory.

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Introduction

• Lest we be like the cat that sits down on a hot
  stove-lid. She will never sit down on a hot
  stove-lid againand that is well but also she
  will never sit down on a cold one anymore.

15
Problems in Pain Management
16
Problems

• Pain appears to be under treated
• Failure to assess pain.
• Failure to quantify pain.
• Fear of addiction.
• Legal constraints of utilizing controlled
  substances.
• Ignorance

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Problems

• 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. 1993269(10)1537-9

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Problems

• 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, DAdamo AP, Goe L. Ethnicity
  and analgesic practice. Ann Emerg Med.
  200035(1)11-16

19
Problems

• 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.
  200223(6)361-5

20
Problems

• 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.
  20059(1)40-43

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Prehospital Pain Management is even worse!
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Prehospital 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. 199716(8)945-9

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Prehospital 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.
  20004(3)205-8

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Prehospital 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. 20026(4)406-410

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Prehospital Pain Management

• Femoral neck fractures are among the most common
  orthopedic injuries encountered in prehospital
  care.

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Prehospital 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).
  200214(3)261-6

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Prehospital 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.

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Prehospital Pain Management

• Without adequate analgesia!

29
What is Pain?

• A sensory or emotional experience or discomfort.
• Single, most common medical complaint.

30
Qualities of Pain

• Organic versus Psychogenic
• Acute versus Chronic
• Malignant versus Benign
• Continuous versus Episodic

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Types of Pain

• Acute pain
• Pain associate with an acute event
• Chronic pain
• Pain that persists after an acute event is over
• Pain that last 6 months or more

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Pathophysiology of Pain
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Pathophysiology

• The generation of pain involves interaction
  between all parts of the nervous system.

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Pathophysiology

• Significant 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.

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Pathophysiology

• Pain is more than a just a feeling or sensation,
  but linked to the complex psychosocial factors
  that surround traumatic events.
• Pain is the brains interpretation of the painful
  stimulus.

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Pathophysiology

• Perceiving pain
• Algogenic substanceschemicals released at the
  site of injury.
• NociceptorsAfferent neurons that carry pain
  messages.
• Referred painpain that is perceived as if it
  were coming from somewhere else in the body.

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Pathophysiology

• Nociception
• Derived from the word noxious meaning harmful or
  damaging to the tissues.
• Mechanical event that occurs in tissues
  undergoing cellular injury.

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Pathophysiology

• Nociceptive stimulus is detected by free nerve
  endings in the tissues.
• Three type of stimuli excite pain receptors
• Mechanical
• Thermal
• Chemical

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Pathophysiology

• Pain fibers are free fibers.

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Pathophysiology

• Pain fibers principally located in the
  superficial layers of the skin.
• Pain fibers also located in
• Periosteum
• Arterial walls
• Joint surfaces
• Falx and tentorium of the cranial vault.

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Pathophysiology

• Deep structures
• Sparsely supplied with pain fibers
• Widespread tissue damage still causes the slow,
  chronic, aching-type pain.

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Pathophysiology

• Visceral Pain
• Ischemia
• Chemical stimuli
• Spasm of hollow viscus
• Over distension of a hollow viscous

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Pathophysiology

• Chemicals that excite pain receptors
• Bradykinin
• Serotonin
• Histamine
• Potassium ions
• Acids
• Acetylcholine
• Proteolytic enzymes

44
Pathophysiology

• Chemicals that enhance the sensitivity of pain
  endings, but do not necessarily excite them
• Prostaglandins
• Substance P

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Pathophysiology

• Types of pain
• Fast Pain
• Felt within 0.1 second after painful stimulus
• Also called sharp pain, pricking pain, electric
  pain and acute pain.
• Felt with needle stick, laceration, burn

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Pathophysiology

• Types of pain
• Slow Pain
• Felt within 1.0 second or more after painful
  stimulus
• Also called dull pain, aching pain, throbbing
  pain and chronic pain.
• Usually associated with tissue destruction

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Pathophysiology

• Pain fibers transmit impulse to spinal cord
  through fast or slow fibers
• A-d (delta) fiberssmall myelinated fibers that
  transmit sharp pain.
• C fiberssmall unmyelinated fibers that transmit
  dull pain or aching pain.

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Pathophysiology

• Pain is often a double sensation as fast pain
  is transmitted by the Ad fibers while a second or
  so later it is transmitted by the C fiber pathway.

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Pathophysiology

• Pain impulses enter the spinal cord from the
  dorsal spinal nerve roots.
• Fibers terminate on neurons in the dorsal horns.

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Pathophysiology

• Impulses then transmitted to the brain via the
  lateral spinothalamic tract

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Pathophysiolgy

• Pain ultimately transmitted to
• Thalamus
• Medulla oblongata
• Somatosensory areas of the cerebral cortex.

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Analgesia

• The brains opiate system
• Endorphins
• Enkephalins

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Referred Pain

• The sensation of pain in a region that is remote
  from the tissue causing the pain.

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Referred Pain

• Certain referred pain patterns are recognized.

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Assessment of Pain
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Assessment of Pain

• Various factors influence the way in which one
  experiences pain
• Physical
• Emotional
• Social
• Genetic
• Age
• Cultural

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Assessment of Pain

• Pain, in most instances, is self-reported.
• This should be considered along with physical
  signs and symptoms when assessing pain.

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Assessment of Pain

• Factors that affect assessment
• Developmental stage
• Chronological age
• Cognitive ability
• Emotional status
• Cultural influence

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Assessment of Pain

• Self-Report of pain
• Have patient describe how they feel.
• For infants and children, rely on care givers.
• Obtain important historical information

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OPQRST-ASPN System

• Onset of Problem
• Provocative / Palliative factors
• Quality
• Region / Radiation
• Severity
• Time
• Associated Symptoms
• Pertinent Negatives

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Assessment of Pain

• Behavioral Observations
• Vocalizations (cry, scream, moan)
• Facial expressions (frown, grimace)
• Body posture (fetal position)
• Motor responses (decreased movement, restlessness)

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Assessment of Pain

• Physiological measurements
• Skin flushing
• Diaphoresis
• Restlessness
• Tachycardia
• Tachypnea
• Elevated BP

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Assessment of Pain

• Physical examination will often give a clear
  indication of the source of the patients pain.

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Assessment of Pain

• How do you quantify pain?

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Infants

• Neonatal Infant Pain Scale (NIPS)
• CRIES
• Crying
• Requires oxygen to maintain sat gt 95
• Increased vital signs
• Expression
• Level of Sleep

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Children 1-7 years

• CHEOPS (Childrens Hospital of Eastern Ontario
  Pain Scale)
• Cry
• Facial
• Child verbal
• Torso
• Touch
• Legs

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Children gt 3 years

• Wong-Baker FACES Scale

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Adult Pain

• Ten Scale most common
• 11 point scale
• 0 No pain
• 10 Worst pain imaginable

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Adult Pain

• Visual Ten Scale

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Adult Pain

• Word / Graphic Scale

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Adult Pain

• Multiple Assessment Tool

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Pain Management
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Pain Management

• Priorities are priorities!
• Scene safety
• BSI
• Treat any life-threatening illness of injury
• Treat pain

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Pain Management

• Strategies
• Removing or correcting the source of the pain

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Pain Management

• Strategies
• Blocking or attenuating the transmission of pain
  impulses to the brain

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Pain Management

• Strategies
• Or, a combination of both

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Pain Management

• Non-medication therapies
• Recognition and empathy
• Distraction
• Muscle relaxation
• Position of comfort
• Temperature regulation
• Physical therapies
• Treat underlying cause

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Pain Management

• RICE
• Rest
• Ice
• Compression
• Elevation

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Pain Management

• Medications that relieve pain are called
  analgesics
• Medication therapies
• Peripherally-acting agents
• Centrally-acting agents

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Pain Management

• Peripherally-acting agents
• Considerable reaction locally to cellular and
  tissue damage
• Pain
• Swelling
• Inflammation

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Pain Management
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Pain Management

• Peripherally-acting agents
• Corticosteroids
• Non-steroidal anti-inflammatory agents (NSAIDs)
• Local Anesthesia

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Pain Management

• Peripherally-acting agents
• Methylprednisolone
• Acetaminophen
• Ibuprofen
• Aspirin

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Pain Management

• NSAIDs
• Effective for pain and inflammation
• Good side-effect profile
• Second generation NSAIDs have better side-effect
  profiles
• Inhibit prostaglandins and other mediators of
  pain and inflammation

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Ketorolac (Toradol)

• Only injectable NSAID in the US
• Analgesic, antipyretic and anti-inflammatory
  properties.

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Ketorolac (Toradol)

• Used for moderate-severe pain
• Orthopedic and soft-tissue injuries
• Popular for ureteral colic.
• Often used in conjunction with centrally-acting
  agents such as morphine.

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Ketorolac (Toradol)

• Onset of action lt 30 minutes IV
• Peak effects 45-60 minutes
• Duration 4-6 hours
• Typical IV dose 30 mg

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Pain Management

• Centrally-acting agents
• Opiates
• Anesthetic gasses used in analgesic quantities
• Atypical agents (ketamine)

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Opiates

• Mainstay of analgesic practice
• Originally derived from the opium poppy plant
• Many now synthetically manufactured

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Opiate Receptors

• ?u (µ ) receptors
• Kappa (?) receptors
• Delta (d) receptors
• Actions
• Inhibit pain
• Cause sedation
• Respiratory depression
• Cardiovascular depression

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Opiates

• Actions
• Act on CNS and organs containing smooth muscle
• Analgesia without loss of consciousness

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Opiates

• Effects
• Analgesia
• Suppresses cough reflex
• Respiratory depression
• Mental clouding
• Mood changes
• Euphoria
• Dysphoria
• Nausea and vomiting

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Opiates

• Effects
• Meiosis
• Decreased gastric, biliary and pancreatic
  secretions
• Reduce gastric motility
• Delay digestion of food in the small bowel
• Decreases peristalsis in the colon (constipation)

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Opiates

• Effects
• Certain opiates (morphine) cause an increase in
  biliary tract pressure
• Certain opiates (morphine) cause peripheral
  vasodiation
• Histamine release (red eyes, pruritis, flushing)

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Opiates

• Morphine

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Morphine

• Named after Greek god Morpheusgod of sleep and
  dreams

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Morphine

• Occurs naturally in the poppy plant
• Among the most frequently used opiates in
  emergency medicine
• Used for moderate to severe pain
• Vasodilator for CHF and pulmonary edema

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Morphine

• Onset of action lt 5 minutes IV
• Peak effects 20 minutes
• Duration 7 hours
• Typical IV dose 2.5-10.0 mg

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Opiates

• Meperidine (Demerol)

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Meperidine

• Synthetic opiatechemically unrelated to morphine
• 1/10 as potent as morphine
• Tends to cause more histamine release than
  morphine and thus more side-effects

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Meperidine

• Causes more euphoria than other agents
• Now removed from many EDs and EMS services due to
  abuse and the availability of better drugs

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Meperidine

• Onset of action lt 5 minutes IV
• Peak effects lt 30 minutes
• Duration 2 hours
• Typical IV dose 25-100 mg

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Opiates

• Hydromorphone (Dilaudid)

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Hydromorphone

• Synthetic opiate
• Effective for moderate to severe pain
• 8-10 times more potent than morphine
• Reportedly produces less nausea and vomiting than
  morphine

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Hydromorphone

• Onset of action lt 5 minutes IV
• Peak effects 30-90 minutes
• Duration 4-5 hours
• Typical V dose 1-4 mg

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Opiates

• Fentanyl (Sublimaze)

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Fentanyl

• Synthetic opiatechemically unrelated to morphine
• Initially an anesthetic induction agent
• Short-acting
• Pharmacological effects similar to that of
  morphine
• Better side-effect profile because of short
  duration of action.

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Fentanyl

• 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.
  199831(3)125-6.

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Fentanyl

• Now routinely used in emergency medicine and, to
  a lesser degree, in EMS
• Chudnofsky CR, Wright SW, Dronen SC, et al. The
  safety of fentanyl in the emergency department.
  Ann Emerg Med. 198918(6)839-40.

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Fentanyl

• Used 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.
  199120(8)913-5.

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Fentanyl

• Proven effective in the prehospital (air medical)
  treatment of pediatric trauma patients.
• No untoward effects during 5 years of prehospital
  use
• Devellis P, Thomas SH, Wedel SK, et al.
  Prehospital fentanyl analgesia in air-transported
  pediatric trauma patients. Pediatr Emerg Care.
  199814(5)321-3.

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Fentanyl

• Onset of action Immediate IV
• Peak effects 3-5 minutes
• Duration 30-60 minutes
• Typical IV dose 25-100 µgs

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Opiates

• Synthetic opiate agonists / antagonists
• Nalbuphine
• Butorphanol

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Synthetic Mixed Opiates

• Sub-class of opiates with both agonistic and
  antagonistic property
• Activate some opiate receptors while blocking
  others
• Reportedly decreases the likelihood of abuse and
  respiratory depression
• Not controlled in many states

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Synthetic Mixed Opiates

• Nalbuphine (Nubain)

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Nalbuphine

• Most common mixed agent used in prehospital care
• Antagonistic properties decrease the potential
  for abuse.

120
Nalbuphine

• Initial studies indicated it was an effective
  alternative to morphine.
• Chambers JA, Guly HR. Prehospital intravenous
  nalbuphine administered by paramedics.
  Resuscitation. 199427-153-8.
• Stene JK, Stofberg L, MacDonald G, et al.
  Nalbuphine analgesia in the prehospital setting.
  Am J Emerg Med. 19886(6)634-9.

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Nalbuphine

• Subsequent 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 200219565-570.

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Nalbuphine

• Because 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
  19991629-31

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Nalbuphine

• Also appears to interfere with general anesthesia
  and maintenance.
• Robinson N, Burrow N. Excessive morphine
  requirements after pre-hospital nalbuphine
  analgesia. J Accid Emerg Med. 199916123-7.

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Nalbuphine

• Probably should have a limited role in emergency
  medicine and EMS.

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Nalbuphine

• Onset of action 2-3 minutes IV
• Peak effects lt 30 minutes
• Duration of effect 3-6 hours
• Typical IV dose 5-20 mg

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Synthetic Mixed Opiates

• Butorphanol (Stadol)

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Butorphanol

• Used by a few EMS systems
• Similar properties to nalbuphine
• Role in EMS has not been widely studied
• Probably should have a limited role in EMS

128
Butorphanol

• Thought to be non-addictive.
• Stadol NS resulted in significant addictions

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Butorphanol

• Onset of action lt 1 minute IV
• Peak effects 3-5 minutes
• Duration 2-4 hours
• Typical IV dose 0.5-2.0 mg

130
Gasses

• Nitrous Oxide (N2O)
• Anesthetic at high concentrations
• Analgesic at low concentrations
• Initially used in dentistry and obstetrics
• Introduced into EMS in the 1970s.
• Effective in treating virtually all types of pain.

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Nitrous Oxide

• Supplied as two-cylinder device (Nitronox) that
  feeds gases into a blender at 5050 concentration
• Self-administered through modified demand valve.

132
Nitrous Oxide

• Proven 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. 198311(11)851-5.
• Pons PT. Nitrous oxide analgesia. Emerg Med Clin
  North Am. 19886(4)777-82,

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Nitrous Oxide

• Effective 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.
  19905(2)145-9.

134
Nitrous Oxide

• NAEMSP has issued a detailed position statement
  regarding its use.
• National Association of EMS Physicians. Use of
  nitrous oxideoxygen mixtures in prehospital
  emergency care. Prehosp Disaster Med.
  19905(3)273-4.

135
Nitrous Oxide

• Probably underutilized for several reasons
• Cost
• Bulky delivery system
• Storage issues
• Lack of understanding regarding efficacy

136
Myths of Pain Management
137
Myths of Pain Management

• MYTH 1 If I give my patient narcotics, they
  will not be competent enough to consent for
  surgery later.

138
Myths of Pain Management

• Myth 1 FALSE
• Concern 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. 20013(5)293-5.

139
Myths of Pain Management

• MYTH 2 If I give my patient narcotics for
  abdominal pain, it will change the physical
  examination findings, making diagnosis difficult.

140
Myths of Pain Management

• Myth 2 False
• The 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.

141
Myths of Pain Management

• Myth 2 False
• Several 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. 1996310861092

142
Myths of Pain Management

• Myth 2 False
• 108 children with abdominal pain.
• 52 morphine
• 56 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.
  2005116978-983.

143
Myths of Pain Management

• MYTH 3 If I give my patient narcotics, they
  will develop respiratory arrest.

144
Myths of Pain Management

• Myth 3 False
• Respiratory 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

145
Myths of Pain Management

• MYTH 4 If I give my patient narcotics, they
  will abuse narcotics

146
Myths of Pain Management

• Myth 4 False
• Because 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.

147
Myths of Pain Management

• Myth 4 False
• In 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. 2000283(13)1710-4.

148
Future Trends in Prehospital Pain Management
149
Future Trends

• Methoxyflurane Inhalers
• Intranasal fentanyl
• Alfentanil (Alfenta)
• Tramadol (Ultram)
• Entonox
• Non-Pharmacological interventions

150
Methoxyflurane

• Inhalation anesthetic with potent analgesic
  properties at low doses.
• Highly-volatile liquid

151
Methoxyflurane

• Came to attention of US EMS people after
  reality-based series Survivor

152
Methoxyflurane

• Widely used throughout Australia in EMS and in
  Defence forces.

153
Methoxyflurane

• Methoxyflurane has a fruity smell that is
  well-tolerated by patients
• Administered via a methoxyflurane (Penthrane or
  Penthrox) inhaler

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Methoxyflurane
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Methoxyflurane

• 3 mL of methoxyflurane are placed onto the wick
  of the inhaler
• Device gently shaken and any excess wiped off
• Inhaler given to patient to self administer
• Supplemental oxygen can be provided.

156
Methoxyflurane

• Pain relief usually begins in 8-10 breaths
• Lasts for 25-30 minutes
• Allows time for IV access and morphine
• Should be used in well ventilated area.

157
Methoxyflurane

• Why dont we have it?
• Methoxyflurane limited to animal use in US.
• Reported liver and kidney toxicity (in anesthetic
  dosesnot analgesic doses)
• US manufacturer quit making Metofane
• Commonwealth of Australia considers the drug safe
  for analgesic usage

158
Intranasal Fentanyl

• Australian 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 IN
• Children 8-12 40 µg IN
• Additional 20 µg doses q 5 minutes

159
Intranasal Fentanyl

• Allowed for early and significant reduction in
  pain.
• Shows great promise for emergency medicine and
  EMS
• Borland ML, Jacobs I, Geelhoed G. Intranasal
  fentanyl reduces acute pain in children in the
  emergency department a safety and efficacy
  study. Emerg Med (Fremantle). 200214(3)275-80

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Alfentanil (Alfenta)

• Chemical analogue of fentanyl (shorter acting)
• Less side-effects than morphine

161
Alfentanil (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. 20018(4)275-8.

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Tramadol

• Synthetic analogue of codeine.
• Has weak opioid agonistic properties.
• Slight abuse potential
• Non-controlled

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Tramadol

• Parenteral form not yet available in US
• 1/10 as potent as morphine
• Onset of action 1-5 minutes IV
• Peak effects 15-45 minutes
• Duration 4.5 hours
• Typical IV dose 100 mg

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Tramadol

• 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. 2001921543-6.

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Entonox

• Single-cylinder pre-mixed 5050 nitrous oxide
  oxygen mixture.
• Available everywhere but the US.
• Gasses tend to separate 26 F (but remix with
  inversion of cylinder)
• Cheaper, less bulky,

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Entonox
167
Entonox

• Study compared 2-cylinder to 1-cylinder system.
• Nitronox safer in cold weather
• No significant clinical differences overall
• McKinnon KD. Prehospital analgesia with nitrous
  oxide/oxygen. Can Med Assoc J. 1981125836-840

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Entonox

• Entonox preferred over Nitronox by prehospital
  personnel involved in study.

169
Non-Pharmacological

• Interesting 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.

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Acupressure

• At 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. 200295(3)723-7.

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Summary

• How can we improve prehospital pain control?
• All personnel should assess for the presence and
  severity of pain.
• Use objective pain measures
• Medical directors need to become more aggressive
  in pain management

172
Summary

• Move 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.
  20026(4)411-6

173
Summary

• Liberalization 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.
  20059(4)377-381

174
Summary

• Field 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

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