Pain Management in EMS and
Trauma
2nd Trimester June 2013 CME
By Silver Cross EMS Staff
Agenda
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System announcements
Pain management in trauma
Managing patients with chronic pain
ALS strip o’ the month - Tachycardia
BLS skill o’ the month – Tourniquets
Pain and EMS
• Whether our patients are suffering from a
traumatic, medical or psychological condition, a
common thread throughout many of our calls is
pain.
• Definition from the International Association for
the Study of Pain: “Pain is an unpleasant sensory
and emotional experience associated with actual
or potential tissue damage…”
Pain Serves a Purpose
• It tells us something is wrong with our body
that we can’t see otherwise
– Appendicitis
– Internal bleeding
• It helps us avoid dangerous things
– We touch a hot stove, we feel pain, we pull away
• It helps us protect damaged body parts
– We shield injuries from accidental contact with
other people or things
What Causes Pain?
• Pain signals are sent to our brain by
nociceptors (no-si-sep-tors)
• A nociceptor responds to damaging stimuli
(heat, pressure, etc.) by sending nerve signals
to the spinal cord and brain.
• This process, called nociception (no-si-sepshun), is what causes the feeling of pain.
The Pain Pathway
(tutorvista.com)
Classifications of Pain
(from Mosby’s Paramedic textbook)
• Acute – sudden in onset, subsides with
treatment
• Chronic – persistent or recurrent, hard to treat
• Referred – pain felt somewhere other than its
origin
– Heart attack felt in arm
– Spleen rupture felt in shoulder
– Gall bladder felt in shoulder blade
Classifications of Pain
(from Mosby’s Paramedic textbook)
• Somatic – pain in muscles, ligaments, vessels,
joints
• Superficial – pain in skin, mucous membranes
• Visceral – “deep” pain, hard to localize, arises
from smooth muscles or organ systems
Some other kinds of pain
• Neuropathic – caused by damage or disease to
the nervous system
– Tingling, burning, electrical “zapping”
– “Pins and needles”
– Bumping the “funny bone”
• Psychogenic – caused by mental, emotional,
or behavioral factors
– No less hurtful than pain from other sources
– Not “all in their head”
Phantom Pain
• Phantom – felt after limb is amputated
– Nerve endings to stump become “confused”
– Signal pain to the brain even though the limb is no
longer there.
Inability to Feel Pain
• Some people can’t feel pain like they should
– Diabetic neuropathy
– Spinal cord injury
– Congenital disorders
• More prone to injury due to lack of “warning”
• May be shorter life span due to increased
injury risk
Pain Tolerance
• Several studies over the years have shown
women typically display lower pain tolerance
than men.
• Unknown whether reason is hormonal,
genetic or psychosocial.
• Researchers suggest men more tolerant of
pain because of “macho” stereotyping, while
feminine stereotyping encourages pain
expression.
Pain Tolerance
• On the other hand, the show “Mythbusters”
found a few years ago that women are more
tolerant of pain than men, so stereotypical
responses may be changing over time.
The Bad Side of Pain
• While pain serves an important purpose, it
also presents a barrier to normal functioning
• Pain negatively affects:
– Attention
– Memory
– Mental flexibility
– Problem solving
– Information processing speed
– Stress levels
Pain Management
• Because pain has as many bad aspects as
good, our goal in EMS is to control pain
whenever possible.
• Joint Commission (JCAHO) says pain is 5th vital
sign after BP, pulse, respiratory, and temp.
• The goal – ZERO PAIN!
Why Zero Pain?
• Cardiac chest pain – zero pain means less
stress on the patient, lowering pulse and BP,
leading to less work for the heart
• Musculo-skeletal pain – zero pain means your
patient is more cooperative, less disruptive
and better able to follow directions
When is zero pain not the goal?
• There are a few times in EMS when we may
want to think twice before treating pain
– Headache – pain medication can mask symptoms
of more serious head injury
– Abdominal pain – pain location used for diagnosis
• When in doubt, call medical control
– Drug-seeking patient – trust your instincts
• If you suspect a drug-seeker, let medical control know
your suspicions (out of earshot of patient)
EMS and Pain
• Prehospital Emergency Care, Jul-Sep 2010… pain in
prehospital emergency medicine affects 42% of
patients…. Pain management is inadequate, as only
one in two patients experiences relief.”
• American Journal of Emergency Medicine, Oct
2007… “women are less likely than men to receive
prehospital analgesia for isolated extremity injuries…
Increasing levels of income were associated with
increased rates of analgesia.”
Why are we not treating pain
adequately?
• Biases and prejudices?
– Poor patients, patients we think are faking it,
patients who are “whiners”
• Fear of medication administration?
– Giving narcotics is a big responsibility, especially if
we are not comfortable with our skills and math
ability
Why are we not treating pain
adequately?
• Our own emotional reaction to someone in pain?
– Our anxiety can cloud our judgment regarding treatment
– A screaming patient makes even the best medic second-guess
• Past issues with medical control regarding medication
administration?
– In the old days, paramedics often got hassled for attempting ALS pain
management. Sometimes, they still do.
Assessing Pain
• The most basic way to characterize pain is the
1-10 scale.
• All reports/narratives with patients in pain should
include a 1-10 rating both before, and after,
treatment
– 1 = no pain
– 10= worst pain ever felt
Assessing Pain
• For children and others with difficulties
understanding the 1-10 scale, you can use the
Wong-Baker scale
– Also called the “smiley face” scale
• They point to the picture that best describes
their pain.
Wong-Baker Scale
Assessing Pain - OPQRST
• All narratives for pain and injury should
include some form of OPQRST
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O – Onset (when did pain start)
P – Palliation/Provocation (what makes it better or worse)
Q – Quality (what does it feel like)
R – Radiation (does it move anywhere)
S – Severity (1-10 scale)
T – Time (can be combined with O, or can refer to whether it
comes and goes or is steady)
OPQRST
• You don’t have to specifically reference each
letter in your report.
– Like any mnemonic, it’s meant to help you remember
important assessment questions, not to be used word-forword.
– But if the information is relevant, it needs to be included.
Assessing Pain
• What does patient look like?
– Obvious distress?
– Guarding injured limb?
– Yelling?
– Calm and controlled?
– Tense?
Assessing Pain
• Remember DCAP-BTLS?
• All painful or injured body parts need to be
exposed and examined.
• And all examinations need to be documented.
– Exception – obvious cardiac chest pain, but if you
are exposing the chest to put on EKG electrodes,
you might as well examine and document anyway.
Assessing Pain – Head-to-Toe
• Depending on the mechanism of injury or the
nature of the illness, a head-to-toe exam may
be called for too.
• Document all head-to-toe exams. If it’s not
written down, it wasn’t done.
• Don’t let severe pain from one part of the
body distract you from injuries on other parts
of the body.
Assessing Pain - Peds
• Sometime starting at the toes and working up
to the head works better with kids.
– May be less likely to freak out.
• Kids are the masters of distracting injuries.
– They don’t understand why a bloody finger is less
important than a deformed leg.
– Take extra care in examining a child in pain
Pain pharmacology/treatment
• Pain medications/treatments address two
components of pain:
– The actual sensation of pain
– The emotional response to pain
• We carry medications and treatments on the
ambulance that address both components
• Don’t forget BLS treatments… often just as
effective as ALS medications, and easier too.
Cold Packs
• Cold packs often a forgotten element of pain
management.
• Reduces swelling and pain in strains, sprains
and fractures.
• When possible, do not put directly on injured
area.
– Can cause tissue damage/frostbite
– Wrap in pillow case or gauze first
Splinting
• Splinting used to stabilize damaged bone ends, or
injured muscles/ligaments.
• But also useful in reducing pain caused by movement
of injured areas.
• Whether a commercial splint, or a pillow and tape… a splint is
powerful weapon against pain.
• Traction splints significantly reduce pain of femur fracture by easing
muscular contraction
• Check distal pulses, movement and feeling (“MSC”,
“CMS”, “PMS”) before/after splinting.
Opiates
• Bind with opiod receptors in the brain
– Alters perception of pain
– Alters emotional response to painful stimulus
Drugandalcoholrehab.net
Morphine
• Commonly carried by EMS
• Chief alkaloid of opium
• Carried by prehospital crews because
– It’s cheap
– It’s been around a long time
– It works without too much fuss
– It’s easy to treat if we give too much of it (Narcan)
Morphine side-effects
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Respiratory depression
Nausea/vomiting
Constipation
CNS depression
Careful administration can prevent many of
these side-effects
Morphine Dosage in Trauma
• Traumatic injury/burn/amputation/frostbite
• 5-10mg slow IVP in 5mg increments as
necessary for pain
– Exception is crush injury – 2mg increments IV/IM as
needed for pain
• Permission from medical control not
necessary, but call with questions or concerns
– Call first if patient has respiratory depression, bradycardia
or is hypotensive
Morphine and Kids
• Kids deserve ZERO PAIN pain too!
• Pediatric morphine dose for fractures or
burns:
– 0.1mg/kg (max of 5mg per dose)
– Or use length-based pediatric tape (Broslow)
– Newborns and young babies don’t get morphine
• Call Medical Control before giving morphine
to kids
Again….
• CALL MEDICAL CONTROL BEFORE GIVING
OPIATES TO KIDS!!!
Morphine and Allergies
• Don’t give if allergic to morphine or other
opiates/opiods.
– Be aware: morphine can cause a small histamine
release in patients not normally allergic to it
• Flushed skin
• Itchy nose/skin
• Allergy to sulfa drugs not a contra-indication
to Morphine Sulfate administration
– Sulfa and Sulfate are not the same thing (not even
close!
Non-narcotic Analgesics
• The only non-narcotic analgesic we carry on
the ambulance is aspirin.
• And ironically, we don’t give aspirin for pain.
– We give it to suspected cardiac patients, as aspirin
is linked to better outcomes for these patients
– May be due to its anti-clotting properties.
Anesthetics
• Anesthetics are CNS depressants.
– Act on nervous tissue
• Two main anesthetics in Silver Cross EMS system
– Tetracaine – local anesthetic
• 1 to 2 drops as needed for hazmat eye exposure
– Nitrous oxide – inhaled anesthetic
• Broken bones, non-respiratory burns, kidney stones
• 50/50 concentration with oxygen
• Contraindications – AMS, shock, abd trauma, facial
injuries, COPD, head injury
Benzodiazapines/Sedatives in Trauma
• Versed (midazolam) used in Region VII for drugassisted intubation, seizures and chemical restraint.
• But medical control may also order Versed as muscle
relaxant in long bones fractures, or to reduce anxiety
in patient with pain.
Some specific examples
• Let’s take a look at some specific examples of
calls involving pain, and what steps we can
take to reduce that pain to ZERO.
Isolated Extremity Injury
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Control bleeding
Splint fractures, sprains and strains
BLS – a cold pack can reduce swelling and pain
ALS – nitrous oxide can help with fractures
– If patient is able to self-administer w/injuries
• ALS – morphine, 5-10mg slow IVP in 5mg
increments every five min as needed for pain.
– No morphine if hypotension from blood loss.
Crush Injury
• Control pain with morphine, 2mg increments
IV/IM as needed for pain.
– Call medical control first if patient has respiratory
depression, bradycardia, hypotension
Burns
• Cooling/flushing smaller (<20% BSA) thermal
or chemical burns with water can reduce pain.
• Water usually not necessary for electrical burns.
• Do not put ice or cold packs directly on burns.
• Don’t pour water over entire body
• Reduces pain for a while, then causes hypothermia
Burns
• Morphine 5-10mg IVP in 5mg increments
every 5 min as needed for pain (no IM).
• Don’t give if pt is in shock (hypotension).
• If you hit the max, and you feel the patient needs more,
talk to medical control
• Nitrous oxide is also an option for burns.
Pediatric Burns
• Remember, kids deserve ZERO pain too!
• Cool smaller burned areas with water or
saline.
• Kids can get morphine.
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0.1mg/kg (max of 5mg per dose)
Or use length-based pediatric tape (Broslow)
Newborns and young babies don’t get morphine
Call medical control first before giving MS to kids
• Consider nitrous oxide if they can selfadminister
Frostbite
• Frostbite victims can get nitrous oxide or
morphine to reduce severe pain.
– Morphine 5-10mg slow IVP in 5mg increments
every 5 minutes as needed for pain.
– Pediatric frostbite – 0.1mg/kg IVP, max 5mg per
dose)
• But contact medical control first in this case.
Hazardous Material in Eye
• Flush each eye with 1000ml NS minimum.
• Reduces pain and removes harmful
substances
• Instill Tetracaine HC 0.5% 1-2 drops to eye for
local anesthesia
– Repeat as needed for pain
– Remind patient not to rub eyes, since lack of pain
may cause patient to harm eye with rubbing.
Chronic Pain
www.webmd.com
• Defined as pain that lasts longer than six
months.
• Can be mild or excruciating, episodic or
continuous, inconvenient or incapacitating.
• May originate with an initial trauma/injury or
infection, or an ongoing medical cause.
• Or can have no cause at all
– No past injury or illness
Patients With Chronic Pain
• Higher rates of depression and anxiety.
• Sleep disturbance and insomnia common.
• Substance abuse highly prevalent in chronic
pain population.
– Drug-seeking behaviors
• Chronic pain may contribute to decreased
physical activity.
– Fear of making pain worse.
The Patient With Chronic Pain
Common Causes of Chronic Pain
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Arthritis
Back Pain
Cancer
Chronic Fatigue Syndrome
Clinical depression
Fibromyalgia
Headache
Irritable Bowel Syndrome
Sciatica
Lumbar spinal stenosis and cervical spinal stenosis
Chronic Pain Treatments
from National Institute of Neurological Disorders and Stroke
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Medications
Acupuncture
Local electrical stimulation
Surgery
Placebos
Psychotherapy
Relaxation
Biofeedback
Chronic Pain and EMS
• Patients with chronic pain call EMS for many
reasons
– Pain recently got worse
– Pain recently changed or moved
– Pain now accompanied by new swelling, heat or
deformity
– Patient hopes EMS can provide pain medications
that MD cannot
EMS Treatment of Chronic Pain
• The EMS provider should remember that
chronic pain is still a medical disorder
– Not all in their head
– Not all patients with chronic pain are drug-seekers
– Not all patients with chronic pain are “whiners”
• Do not make light of their condition
• But do contact medical control with your
concerns before providing ALS pain relief
EKG Strip O’ the Month
• Sinus Tachycardia
Dysrhythmias Originating
in the SA Node (5 of 10)
Rules of Interpretation
Sinus Tachycardia
Rate
Rhythm
Pacemaker Site
P Waves
Greater than 100
Regular
SA node
Upright and normal
PRI
Normal
QRS
Normal
Sinus Tachycardia
• Clinical Significance
– Not really a dysrhythmia,
response to underlying problem
*May be benign or compensatory mechanism
*increases myocardial oxygen demand
*beats >140 can decrease CO
Sinus Tachycardia
• Can precipitate ischemia or infarct
• Cardiogenic shock with associated MI
• Caused by ingestion of stimulants
(caffeine, nicotine)
• Caused by increased catecholamines
From anxiety, fear, pain, stress
Sinus Tachycardia
• Caused by excessive doses of atropine,
epinephrine, norepinephrine
• INCREASES THE WORKLOAD AND
OXYGEN DEMAND OF HEART causing
chest pain and ischemia to muscle
Sinus Tachycardia
• Treatment modalities
– Treat the underlying cause
– In healthy individuals, dysrhythmia
subsides gradually when cause removed
BLS Skill o’ the Month Tourniquets
• If bleeding can’t be controlled with direct
pressure, the next step is tourniquet.
• Tourniquets fell out of favor in EMS several
years ago, but are back in favor now
• Thank the military – newer models developed
during wartime work better and cause less
harm than older devices
Tourniquets
If you are interested in purchasing
tourniquets for your agency, give us a
call… we can’t recommend specific
models, but we can refer you to other
agencies who can talk about their
experiences with certain brands.
Tourniquet tips
• A blood pressure cuff can work as a tourniquet
in an emergency.
– Make sure to monitor it to maintain pressure
• Don’t use wires, belts or other materials that
can cut into the skin.
• Tourniquets on legs will usually have to be
applied more tightly than tourniquets on
arms.
Questions?
• Questions? Please type them into dialogue
box to the right of this screen (if viewing live)
• Please call 815-300-7130 or email
afinkel@silvercross.org if you think of
questions later.