The next topic for discussion in the NAEMSP Dialog will be Prehospital
Pain Management. Confirmed invited participants include Michel
Galinski, MD from the SAMU / SMUR ambulance service in Paris, France.
He was the lead author of a study published in the July/Sept. 2010
issue of PEC entitled, "Prevalence and Management of Acute Pain in
Prehospital Emergency Medicine." Keith Wesley, MD is the State EMS
Medical Director for Minnesota and was an author of the NAEMSP
Position Paper on Pain Management. Bryan Bledsoe, DO is a Clinical
Professor of Emergency Medicine at the University of Nevada School of
Medicine and the author of numerous EMS textbooks and journal
articles.
The discussion will be begin soon, so please invite any of your
colleagues who may be interested to join us. They may become a part of
the Dialog group by visiting http://groups.google.com/group/naemsp-dialog
and clicking the link to join this group.
Thanks,
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
The management of pain is an important topic that, in many EMS
systems, does not get enough attention. This session of the NAEMSP
Dialog will explore the issue and challenges of pain management in the
field. This session begins today.
Invited participants for this session will include:
Paul Middleton, Paul Simpson and Jason Bendall - They are authors of
the paper entitled “Effectiveness of Morphine, Fentanyl, and
Methoxyflurane in the Prehospital Setting” that was published in the
October-December issue of PEC. They are all affiliated with the
Ambulance Research Institute at the Ambulance Service of New South
Wales in Rozelle, NSW Australia.
Michel Galnski, MD is the lead author of the paper entitled
“Prevalence and Management of Acute Pain in Prehospital Emergency
Medicine” in the July September 2010 issue of PEC. He is with Hopital
Avicenne, SAMU in Bobigny, France.
Keith Wesley, MD is an author of the 2003 NAEMSP Position Paper
entitled “Prehospital Pain Management”. He is the State EMS Medical
Director for Minnesota and Medical Director for the HealthEast Medical
Transportation in St. Paul, MN.
Bryan Bledsoe, DO is a prolific author of EMS textbooks and journal
articles – many of which have addressed prehospital pain management
issues. He is a Clinical Professor of Emergency Medicine at the
University of Nevada School of Medicine and an attending emergency
physician at University Medical Center of Southern Nevada in Las
Vegas.
Michael Dailey, MD is the author of the chapter “Sedation and
Analgesia for the Prehospital Emergency Medical Services Patient” in
the text on Emergency Sedation and Pain Management. He serves as
Medical Director for the Colonie EMS and other agencies in the Capital
District of New York. He is also the Director of Prehospital Care and
Education and an Assistant Professor of Emergency Medicine at the
Albany Medical College.
This session will begin, per our usual process, with some initial
discussion with the invited participants. The Dialog will be opened up
for discussion among all Dialog members shortly thereafter. Please
invite any colleagues who may be interested in this topic to join in
by enrolling at http://groups.google.com/group/naemsp-dialog.
--- Mic
Mic Gunderson
Editor / Moderator
NAEMSP Dialog;
President, IPS
To get things started at a high level with our invited participants, I'd
like to try and frame the areas we might want to address during the course
of this discussion.
What are some of the open questions that need to be answered through
research or policy development related to prehospital pain management? What
controversies are out there that need to be explored? What else should we
address during this conversation over the next few weeks?
I'll first ask this of the invited participants and will then open it up to
all shortly.
--- Mic
Mic Gunderson
Editor / Moderator
NAEMSP Dialog;
President, IPS
I see the issue breaking down into the following areas
1. Appreciation for the role of pain management
2. Assessing pain scores
3. Determining the most appropriate for the condition
4. Determining what the goal is for pain relief
5. Addressing the special needs of pediatrics
As for controversies? I would suggest we dis-spell the following
1. Pain management alters the physical exam
2. Pain management removes a patient's ability to provide informed
consent for additional treatment
3. Is there a role for holistic measures such as bio-feedback,
acupressure, aroma therapy, etc.
Keith Wesley, MD
All,
The medical literature shows that EMS does a poor job of administering analgesia to
our patients in pain. But really, should that be a surprise? I have yet to see a paper
that demonstrated that in-hospital analgesia is performed adequately.
Can we hold EMS to a higher standard than we expect of the rest of medicine? Of
course we can! EMS is a unique environment where there is generally a provider or
team of providers and a single patient; what needs to be present are reasonable
protocols and opportunity for medication administration.
Keith's topics are a great place to start. What are the best agents for us to use? Is
there a place for non-steroidal medications in EMS, or should the basic agents used
be inhaled, like nitrous oxide, or opiates, such as fentanyl.
Pain scores are a great topic. To quote The House of God "You have to check a
temperature to find a fever". You don't find pain unless you look for it. How are we
looking for the fifth vital sign and are these techniques validated? In fact, do we need
pain scores at all, or do we need to encourage verbal assessment and recording?
After all, has anyone ever heard "Boy does it hurt--it's an 11 out of 10!"
The authors of some great studies and papers are going to be on this thread.
Another great question: Does anyone have any new techniques to teach pain
management to new and currently practicing providers?
Michael
Michael W. Dailey, MD FACEP
This gets us off to a good start - thank you Keith and Mike. Our other
invited participants (Bryan, Paul M, Paul S, Jason and Michel) are
still welcome to chime in with their thoughts.
But, at this time, I'm going to open it up to the entire group. What
do each of you think are the open questions that need to be answered
through research or policy development related to prehospital pain
management? What are the controversies are out there that need to be
explored? What else should we address during this conversation over
the next few weeks?
A gentle reminder to all - our decorum is that all posts should
include your name and affiliation. This is a moderated forum, so if a
post is submitted without this information, you may be asked to
resubmit with it included (http://groups.google.com/group/naemspdialog/web/guidelines-of-decorum).
Thanks,
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
Looking forward to this important topic.
Dr Koehler
Alaska
I think the topic of prehospital pain management is a very important
one. This is a weapon in the paramedic arsenal that is often
overlooked when indicated. I have written about this specific topic a
few times on my blog and as an advocate for more liberal use of pain
management, I will provide some research abstracts to get the ball
rolling. I am especially excited to see the prestigious panel for
this topic.
From Pubmed:
[1]
Am J Emerg Med. 2010 Mar 25. [Epub ahead of print]
Predictors of pain relief and adverse events in patients receiving
opioids in a prehospital setting.
Bounes V, Barniol C, Minville V, Houze-Cerfon CH, Ducassé JL.
SAMU 31, Pôle de médecine d'urgences, Hôpitaux Universitaires, 31059
Toulouse cedex 9, France.
Abstract
OBJECTIVE: The aim of the study was to analyze factors predicting pain
relief and adverse events in patients receiving opioids for acute pain
in a prehospital setting.
METHODS: In this prospective, observational clinical study, adult
patients with a numerical rating scale (NRS) score of 5 of 10 or
higher who required treatment with intravenous opioids for pain
control were included. The primary outcome variable was final
analgesia defined by an NRS score of 3 of 10 or lower upon arrival to
the emergency department. Univariable and multivariable analyses were
performed to identify predictive factors of pain relief and adverse
effects.
RESULTS: In total, 277 patients (age, 49 ± 22 years), 205 (74%) of
whom were male and 154 (56%) with a traumatic pain were included in
the analysis. Median (interquartile range) NRS scores at baseline and
at discharge were 8 of 10 (7-10) and 3 of 10 (2-5), respectively. The
final model had 3 independent variables reaching significance.
Physician-staffed ambulance transportation (odds ratio [OR], 2.42; 95%
confidence interval [CI], 1.07-5.49) was the only independent
predictor of patients' final pain relief. High initial pain scores and
acetaminophen use were predictive factors for failure of analgesia
(OR, 0.79; 95% CI, 0.68-0.93 for one unit/10; P < .01; and OR, 0.40;
95% CI, 0.21-0.77; P < .01, respectively). In the entire sample, 25
(9.0%) presented one adverse effect, all mild to moderate in severity,
with no significant predictive factors.
CONCLUSION: Despite advancement in prehospital pain management, pain
relief at discharge is still inadequate in some patients. Finally, one
important message of our study is that patients in pain have to be
transported by well-equipped and staffed ambulances to reevaluate and
alleviate pain.
[2]
J Eval Clin Pract. 2010 Aug 13. [Epub ahead of print]
Exploratory cross-sectional study of factors associated with prehospital management of pain.
Siriwardena AN, Shaw D, Bouliotis G.
Professor of Primary and Prehospital Health Care, Faculty of Health,
Life and Social Sciences, University of Lincoln, Lincoln, UK and
Associate Clinical Director, East Midlands Ambulance Service NHS
Trust, Lincolnshire Divisional Headquarters, Cross O'Cliff Court,
Bracebridge Heath, Lincoln, UK.
Abstract
Abstract Rationale, aims and objectives Improving pain management is
important in pre-hospital settings. We aimed to investigate how pain
was managed in pre-hospital suspected acute myocardial infarction
(AMI) or fracture and how this could be improved. Method We conducted
a cross-sectional study in Lincolnshire using recorded suspected AMI
and fracture between April 2005 and March 2006. Outcomes included pain
assessment, improvement in pain scores and administration of Entonox,
opiates or GTN (in AMI). Results We accessed 3654 patients with
suspected AMI or fracture. Pain was assessed in over three quarters of
patients but analgesics administered in under two-fifths. Assessment
was more likely in patients with suspected AMI (OR 2.05, 95% CI [1.70,
2.47]), and who were alert (OR 3.55, 95% CI [2.32, 5.43]). Entonox was
less likely to be administered for suspected AMI (OR 0.11, 95% CI
[0.087, 0.15]) or by paramedic crews (OR 0.56, 95% CI [0.45, 0.68])
but more likely to be given when pain had been assessed (OR 3.54, 95%
CI [2.77, 4.52]). Opiates were more likely to be prescribed for
suspected AMI (OR 1.30, 95% CI [1.07, 1.57]), in alert patients (OR
1.35, 95% CI [0.71, 2.56]) assessed for pain (OR 2.20, 95% CI [1.73,
2.80]) by paramedic crews. Conclusions This exploratory study showed
shortfalls in assessment and treatment of pain, but also demonstrated
that assessment of pain was associated with more effective treatment.
Further research is needed to understand barriers to pre-hospital pain
management and investigate mechanisms to overcome these.
These are just two of the most recent studies.
Adam Thompson, EMT - P
Paramedicine101.com
I am looking forward to this discussion. Pre hospital pain management is one of the
ways we really can make a difference.
Margaret A. Keavney
I would like to see some discussion about drug seeking and the degree to
which perceptions about drug seeking hinder appropriate pain management in
the field. Also, reasons why so many jurisdictions require paramedics to
call in for orders for analgesics when so many (arguably far more dangerous)
drugs can be given by standing order. Finally, some discussion about
entering patients into a pain management protocol as opposed to dictating a
specific dose that may or may not be therapeutic for the patient.
Thanks,
Tom
-Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)
ems12lead.com
@tbouthillet / @EMS12Lead
Hello to all,
Thank you for the opportunity to participate in the forum. Being new to this forum,
this seems to me to be a great initiative. The ideas outlined to date will make for
interesting discussion. I would also like to see the qualitative aspects of pain
management discussed over the coming weeks, with regard to paramedic decisions
about how legitimate a patient’s stated pain really is. We use a verbal numeric
rating scale in our Australian service, but anecdote suggests that our paras have
little faith in the patient’s reported pain score and this important field is absent on
patient care records in almost half of cases involving analgesia administration. So if
we are not using pain scores, what are we basing our assessment of pain on and
what is underpinning our decision to provide analgesia or not, and how much? As
mentioned previously by another forum participant, is getting a pain score really the
way to go?
Looking forward to chatting further.
Paul Simpson
Paramedic Research Fellow/Intensive Care Paramedic,
Ambulance Research Institute
Ambulance Service of New South Wales, Australia
Paul,
Thanks so much for participating in this discussion. It will be great
to have a perspective from the EMS community in Australia.
For everyone's reference, the paper that Paul Simpson was a
contributing author on (with Paul Middleton and Jason Bendall and
others) is now posted in the files section of the NAEMSP Dialog site.
It is there along with the paper by Michel Galinski et al and the
NAEMSP Position Paper on pain management that Keith Wesley was a coauthor on. I'll put some links to these papers on the pain management
resource page as well in the coming days.
Here is a link to the files page - look for files that start with
"Topic004-" as they will be the ones associated with the pain
management topic.
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
Hi All,
I too am looking forward to this discussion. Over here in the UK we seem to have
some positives to our management of pre-hospital pain.
We have a number of options available to us including entonox, paracetamol,
ibuprofen, oral morphine and Morphine IV. By far though, the best thing that we
have is the ability to make the decision on what analgesia and how much to give the
patient.
For severe pain, when I am giving Morphine, my dose is simply titrated to effect. My
normal standard max dose is 20mg IV but there have been times when I have
exceeded that dose, as long as I have been able to rationalise why and show on the
clinical report that the patient was not suffering any of the troubling side effects at
that time. Basically if the patient is in significant pain, BP, pulses, GCS, resps and
SaO2 are all stable and within normal limits , then they will be given Morphine
titrated to effect.
From what I have witnessed from my travels to the States and reading many US EMS
blogs, there seems to be much tighter reigns on the administration of opioids in the
pre-hospital environment.
I am a staunch advocate for actively treating pain in the prehospital arena. Even on
short journeys to hospital, if the patient is scoring their pain above 5 on a 0-10 scale,
I will intervene with an appropriate analgesic. It takes time for the patient to be
triaged and seen by a Doctor, so why make the patient suffer for longer than is
absolutely necessary?
Unless you are still one of those providers that believes analgesia should be withheld so that the A&E/ER doc can see where the patients pain is and how severe it is?
Mark Glencorse,
Paramedic Team Leader,
North East Ambulance Service NHS Trust, UK
Author of www.999medic.com
Applicability of pain scales is problematic. In our practice, we are arbitrarily held to
The Joint Commission (TJC) standards on pain assessment. However, this is really
the only national standard which is currently enforced in hospital. In my protocols, I
have given guidance to my prehospital providers to assess and treat pain
aggressively with scores of 5 or greater being treated with the option of NSAID
(Ketorolac) or OPOID (Fentanyl) depending on the mechanism of injury (MS vs
Trauma). Also is given the leeway to hold analgesic due to other influencing factors
(chronic opiod patient whom appears sedated already, conflicting
medications/interactions, vital sign/mental status abnormalities) as long as they
can paint that picture to me in their prehospital report as to the reasoning process
on why they have withheld medication.
Concur with the recent post on times to treatment in the Emergency Department.
How may of us have had lines of ambulances waiting out the door or down a hallway
for someone to become available to treat the patient. This may be the patients only
choice of analgesic for a significant period of time and as we all know, treating pain
appropriately and aggressively up front reduces long term useage and pain
syndrome development.
To me this is really not that controversial a topic other than what are we using for a
standardized scale or national equivalent other than a commission
mandated/created false standard.
respectfully,
Timothy Talbot, MD
Chief, Department of Emergency Medicine
Chief, Fort Campbell Emergency Medical Services
Medical Director, Fort Campbell Fire and Emergency Services
First off....Thank you Mic for launching this dialogue. Most of the folks who call 911
hurt, are having difficulty breathing, have had something bad happen to them, feel
real sick, or are with someone who they can't wake up. I'm a firm believer in
addressing a patients "inspiration for calling 911" as part of any treatment protocol.
Since pain is involved in many if not most of the presenting problems we deal with I
believe that pain management is an essential part of our practice. There are a few
issues related to this topic that I would love to have our expert group chat about in
addition to those already mentioned.
Many if nor most experienced (and not so experienced) paramedics are confident
that they can tell if someone is faking, over dramatizing, drug seeking, or really
suffering. It seems as if they rely on facial expressions, body posture, skin color, and
??? to make these grand certain pronouncements. Yet, the American Pain Society
http://www.ampainsoc.org/ maintains that the only reliable measure of pain is
patient report. They even hint that the more experienced the clinician the worse
they are at accurately assessing the pain of another. What are your thoughts on this
issue?
Many of the people we care for are having nausea and are experiencing fear along
with their pain. It would be nice to hear what people thing about managing mixed
manifestations of suffering.
As we expand our pharmaceutical options in this domain the issue of drug diversion
and the addicted clinician arise. It would be interesting to hear about systems to
make sure medications go into patient veins not provider veins.
Cheers,
Mike Taigman
Old Medic
General Manager AMR AlCo
Mike,
I too have seen many, many providers making the judgement on the patients pain
for them. Yes, there are some times that the patient is very clearly and
obviously in pain and if it is a result of an obvious traumatic injury, then it
is a very easy step to move towards the higher levels of the 'analgesic ladder'
sooner rather than later.
Where the real difficulty comes in is with the patients who call for a pain
related illness e.g. the chronic undiagnosable abdominal pain. Again, if someone
is clearly distressed then its an easy decision to make, but what about those
who are outwardly coping with their pain ; who show no physiological alterations
in BP or pulse, who look comfortable and at relative ease, but who score their
pain at 10 out of 10?
I still remember the quote from McCaffery & Beebe (1989) that was drilled into
me whilst completing my nurse training in the early 90`s.
"pain is whatever the person experiencing it says it is, and exists where [the
person] says it does"
I still go with this opinion and try to always believe what the patient tells
me. That doesn't mean that the patient is going to get Morphine from me though,
they may get something lower down the ladder and see how that works for them (if
the travel time allows for that).
My Mantra has always been, and will always be "If in doubt I will always go with
the patients pain score, I would never want to withhold analgesia from a patient
who needs it just because I suspect that they maywant it instead.
As for the nausea that goes along with the patients condition or is caused
through the administration of an opioid, that is something that is currently
being investigated with a research project within my trust.
Our national guidelines allow for the use of metoclopromide as an anti emetic,
however my service has chosen not implement this as the have found that the
evidence points to nausea and vomiting being vastly minimised through the
appropriate slow administration of Morphine along with a titration to effect
rather than a bolus dose. I have found this to be true, but I would still like
and anti-emetic to be able to give patients who are nauseous or vomiting
already
Mark
Mark Glencorse,
Paramedic Team Leader,
North East Ambulance Service NHS Trust
Blog: www.999medic.com
Twitter : @UKMedic999
Skype: markglencorse
Mobile: 07850 042620
(Posted on behalf of Michel Galinski, MD, SAMU, France)
Hi
I would like to answer to the question about the "risk" of pain
management. Currently there are lot of studies done all along the
last 20 years about acute abdominal pain. Should we treat pain before
the surgeon see the patient. Most of studies said Yes. The pain
management with morphine of an abdominal pain, in children or in
adults, does not change the diagnostic. (Pace S.Acad Emerg Med
1996;3:1086-92; Attard AR. BMJ 1992;305:554-6). In ours days
diagnosis are helped by UltraSonography or tomodensitometry scan.
The clinician good sense could say that it is easier to question and
to make an examination of a patient about his pain when he has no
pain any more (after treatment).Imagine a patient who is crying or moving
because of his acute pain. So we could say that pain management
improves the physical exam.
Front of an acute coronary syndrome what is the utility of the chest
pain. The patient called because of it. We know that. But arguments
about an acute coronary syndrome come fron the patient history,
cardiovascular risk factors , characteritics of pain (which could be
obtain even pain is disappeared) and EKG;
Maybe the real questions could be: is there a risk to not treat a
severe pain? Is it necessary to treat pain in the prehospital
setting? If yes how to do that? What are the limitations?
Well that did not work... let's try again. Pardon the technical
glitch. --- Mic
(Re-posted on behalf of Art Samaras, Morristown, NJ [to keep the
entire pain discussion in the same thread])
Dr Wesley provided several controversies for this discussion on his
post, the first being that pain management potentially altering the
physical exam.
I'd like to hear some of the opinions of the contributors on this
issue. What ailments present where this is specifically an issue?
For example, in severe burn patients, pain does not often assist the
receiving team with being able to assess the patient. Some of our
neurosurgeons, on the other hand, often ask that we withhold
prehospital pain management from a patient with a suspected neuro
impairment until they have had the opportunity to assess the
patient.
Looking forward to the conversation.
Thanks,
Art Samaras, NREMTP, FPC
Atlantic Ambulance
Morristown, NJ
Hi
about the necessity of pain management.
The first question is: Can we treat every kind of pain in emergency setting? Someone
said that surgeon do not want a pain management for some patients before he see
him?
This question has been treated for a long time. Lot of studies has be done about
acute abdominal pain with this question : if we treat the pain with morphine is the
diagnosis going to be more difficult to do ? the answer is : NO. We can treat acute
abdominal pain with morphine the diagnosis is not going to be altered (Pace S Acad
Emerg Med 1996;3:1086-92 ; Attard AR BMJ 1992;305:554-6); The clinical good
sense could also say that it is easier to question a patient without pain that a patient
with pain.
Example: In front a suspicion of acute coronary syndrome, the pain is not useful for
the diagnosis. The arguments for the diagnosis come from the patient history,
cardiovascular risk factors, some characteristics of pain (localization, irradiation,
etc) and the EKG. In the other hand the pain is stressful which is not good for a
coronary syndrome.
We could reverse the question: what are the risk for the patient if we do not treat
his pain?
In the eighties Anand demonstrated that the treatment of pain in premature during
surgery reduced circulatory and metabolic complications. (Anand KJ Lancet
1987;1(8524):62-6.) . There is not currently study about relation between acute
pain in prehospital setting and such complications. But we know that after multiple
ribs fracture with pulmonary lesion an efficient pain management (epidural versus
systemic opioid) reduces the rate of pulmonary infection and artificial ventilation
days (Eileen M Surgery 2004;136:426-30).
Michel Galinski
CNRD
Centre National de Ressources de lutte contre la Douleur
Hôpital Armand Trousseau
26, av Arnold Netter
75571 Paris Cédex 12
Tel :
+33 144735426
Secrétariat: +33 144735421
Hi All,
I am new here, so first an introduction.
I am an Anaesthesiologist in solo private practice in Johannesburg,
South Africa. I do no prehospital work now, but spent 34 years as a
volunteer in mountain rescue, some of that time representing the
Mountain Club of South Africa on the international Commission for
Alpine Rescue ( Medical Commission).
As has been said several time already, pain is nasty and needs to be
treated, but it is only part of the unpleasant experience that the
patient will have during the initial part of an injury or illness. At
least the main treating doctor ( or Paramedic where applicable )
should introduce himself and make physical contact such as holding the
patient's hand, or feeling the pulse frequently, listening to the
breathing with a stethescope or however else one can touch. As soon as
possible the situation and what is going to happen should be explained
to the patient in simple language, and re-explained as frequently as
needed because injury, pain, and drugs will prevent the patient from
remembering what you told him. I know as well as you do that many
places are too noisy to hear anything, but the contact is the
important thing here - the patient thinks that somebody cares about
him as a person rather than an item to be removed from one place to
another. It is almost always possible to communicate with the patient
and try to understand what he is replying. If the patient knows you,
even in a very little way, he will trust you much more, and so feel
better about himself within the situation and fear will be decreased.
He also needs to be kept warm ( or cool in a hot climate ), thirst
can be decreased by intravenous fluids or drinking as suitable, noise
must be decreased as much as possible, as should vibration and other
movements that can cause motion sickness, he needs enough oxygen to
prevent dyspnoea at altitude, an empty bladder and where possible a
full stomach. Nausea can be minimised, and I favour cyclizine because
it prevents both drug induced nausea and motion sickness.
Non-drug methods to decrease pain are moving the patient as little as
possible but remember to move him enough to prevent "pressure sores",
padding and immobilisation of injured parts, Transcutaneous Electrical
Nerve Stimulation (= TENS, a stupid man's accupuncture that is easy to
use and may have good analgesic effects but discuss this with the
helicopter's pilot first ).
Standard analgesics have been mentioned before, but a few others that
can be thought about are ketamine ( Ketalar ) which is an excellent
analgesic in it self, but also is a NMDA nerve receptor antagonist and
prevents "wind-up" which will increase any pain that remains for a
long time. This drug can be given by any route, in doses of the order
of 0,1mg / kg body mass IV, 1-2mg/kg body mass IM or Sub Cutaneous,
0,5 - 1 mg/kg body mass by mouth ( well dilute since it tastes
awful ). Since safe anaesthetic doses are about ten times these doses,
you do not need to worry too much about the dangers of the drug. It
works very rapidly but for a short time after IV , and takes about 30
- 45 minutes after oral dosing. It can be given in these doses with
full doses of other analgesics.
For those who have in hospital experience, nerve blocks with local
anaesthetics can be used, but with due respect for their dangers.
In hungry neonates plain sucrose ( cane sugar ) given by mouth seems
to decrease pain and suffering.
Anxiolytics and sedatives can help but they will increase the dangers
of analgesics and may make care of the patient in an unstable
environment more difficult.
Arthur Morgan
Hi
About the treatment of pain:
We have two principles
1 - the treatment has to be adapted to pain intensity, patient and pathology
2 - the different pain killer should be associated (multimodal analgesia)
For sever pain (VAS or NRS equal or upper than6/10 or VRS =4), the reference is
morphine.
Studies comparing morphine with fentanyl or sufentanil showed that there was not
difference for relief pain at 30 minutes. (Galinski et al Am J Emerg med 2005;
Bounes et al Ann Emerg Med 2010).
Morphine is titrated. In emergency department, patients with VAS equal or upper
than 7/10, an IV injection of 3mg or 2mg (if weight lower than 60 kg) every 5
minutes resulted in a pain relief in more than 80% of patients (lvovschi et al am j
emerg med 2008).
Other pain killers are: non steroidian anti inflammatory drugs (NSAI), paracetamol,
nitrous oxid. All this treatment can be associated togother and with morphine. The
association of NSAI with morphine, decrease the risk of morphine side effect
reducing the dose for the same pain relief.
Concerning ketamine: low doses of ketamine (0,1 to 0.3 mg/kg IV) has been
demonstrated efficient in post operatve setting reducing dose and side effects of
morphine, and improving analgesia in some cses . But in prehospital setting there
is currently only one study (controlled and randomised study) which demonstrated
a reduction of morphine comsumption. But here was not improvement of pain relief
neither reduction of morphine side effects (galinski Am j Emerg Med 2007).
ketamine is not exactly an antalgic drug,; it is an antihyperalgesic drug and sedative
drug.
Ketamine can be use doses of 0.5 to 1 mg/kg IV, but it is more a sedative action.
2 to 3mg/kg IV are anesthesiologic doses.
Michel Galinski
CNRD
Centre National de Ressources de lutte contre la Douleur
Hôpital Armand Trousseau
26, av Arnold Netter
75571 Paris Cédex 12
Tel :
+33 144735426
Secrétariat: +33 144735421
One aspect that has not been discussed is restrictive state mandated protocols that
limit a medical director's ability to choose appropriate analgesics for those
paramedics working under her/his license.
For example, Arizona, USA, where I live, has very archaic and restrictive protocols
which must be adhered to by all EMS services. Morphine is the only opioid allowed.
Paramedics are not allowed to give fentanyl. Only nurses can give fentanyl in the
field, which at least allows flight nurses to use it. AZ also has a system of base
hospitals that mandates that every EMS service be tied to a base hospital. The base
hospitals have what are called "prehospital coordinators" which are always nurses,
most of which have never spent more than an hour or two in an ambulance. One of
them said to me that "fentanyl has no place in EMS. Our ER doctors cannot even use
it."
When one lives in a place like Arizona, it's useless to discuss choices in prehospital
analgesia because there are none. And it's useless to discuss titration, because the
state protocols do not mention it. They call for set doses, regardless of patient
weight or other factors that might enter the minds of somebody who knew what
s/he was doing.
As an EMS educator, I go beyond state protocols and teach my students the theories
of pain management, but they will never be able to use them if they practice in
Arizona.
I would be interested to know whether or not other states have such restrictive
rules.
Gene Gandy, JD, LP, NREMT-P
EMS Educator
Tucson, AZ
Gene,
Great topic. In 2008 we did a survey of states to find what analgesics were available
for EMS. 26 states allowed fentanyl to be used, 25 on standing orders, with one
requiring physician contact. This is up by about 30% from 4 years prior, so there are
changes happening across the country. When we worked to add fentanyl to the New
York State formulary in 2007 we were met with great resistance by the regulators,
who were concerned about the perception of loose controls on EMS and the high
propensity for diversion of fentanyl. We made the case, and have a successful,
although restrictive program in New York. In NY we have 18 regions, each with
different protocols, but all approved by a State Bureau of Narcotics Enforcement,
Bureau of EMS as well as Medical Advisory Council and EMS Council--an arduous
process to change protocol and formulary, but possible. For now, study the problem,
optimize pain management with morphine, and find the pathway that it takes to
negotiate the way through the regulators. Dr. Galinski highlights a reasonable
protocol for rapid titration of very small doses of morphine that may serve as a
stepping stone for you.
I was convinced from my practice in EMS and in the ED that fentanyl was the best
choice of prehospital opiate before I added the use of the mucosal atomizer to my
skill set, and now I am even more convinced. Fentanyl intranasal is hands down the
best way to management acute traumatic pain in children, and for adults, the rapid
onset, short half-life, minimal histamine release and hemodynamic profile make it
the all-round best agent. Dr. Galinski's study comparing F and M was small and had
a non-significant trend toward better relief with F. More than anything else it, and
work by others including Gallagher in the ED, have demonstrated that the best way
to get relief of pain for our patients is to give those administering analgesia the
latitude to give more if needed.
As Dr. Galinski says, the treatment must "be adapted to pain intensity, patient and
pathology." Our providers have the skill to manage pain; we need to give them the
tools they need to do it.
MD
Michael W. Dailey, MD FACEP
Director of Prehospital Care and Education
Associate Professor of Emergency Medicine
Albany Medical Center
518/ 262-3773
One issue that I have not been able to resolve is that in tiered EMS systems, patients
that may need analgesia are triaged to BLS units. For example, the fall with arm/hip
fracture or headache may be triaged to BLS providers.
How do we reconcile this?
Derek Isenberg, MD, NREMT-P
Medical Director
Mercy EMS
Mercy Catholic Medical Center
Department of Emergency Medicine
501 South 54th Street
Philadelphia, PA 19143
215.748.9740
215.748.9208 (fax)
Gene,
I read your post with great interest and dismay. As the State Medical
Director for Colorado, it is hard for me to understand how statewide
mandates get passed that are so restrictive that they negatively affect
patient care. How can a prehospital provider possibly provide adequate care
with only one opioid choice? What do they do when a patient requires pain
management and the patient is allergic to morphine? Pain is too prevalent of
a complaint in EMS to not give paramedics appropriate tools to manage. A
single opioid is simply inadequate and not providing early pain management
is simply poor patient care.
Fentanyl is such a safe and effective medication available for field use
that I almost cannot believe that any EMS agency would function without it
in their toolbox. I had the good fortune of being involved with a very
progressive private ambulance service (Pridemark Paramedics) from 1999 –
2005. During that time we were able to complete a fairly extensive study of
prehospital pain management and the use of fentanyl and morphine. From the
study data we published an article that dealt with the safety and efficacy
of fentanyl in over 2100 patients (PREHOSPITAL EMERGENCY CARE 2006;10:1–7).
We had plans to also publish some of that comparative data (morphine vs
fentanyl) but unfortunately I left Pridemark prior to completing that part
of the study. However, fentanyl is clearly a safe and very effective opioid
available for prehospital use.
Please feel free to share the article published in Prehosital Emergency Care
with the appropriate powers in Arizona. If I can be of any help I would be
happy to personally share my perspective as well as the data from our study
and what we learned.
I have included the abstract below.
Arthur Kanowitz MD FACEP
State Medical Director
Emergency Medical and Trauma Services Section
Health Facilities and Emergency Medical Services Division
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver. Colorado 80246-1530
office 303 692-2984
mobile 720 641-3540
SAFETY AND EFFECTIVENESS OF FENTANYL ADMINISTRATION FOR
PREHOSPITAL
PAIN MANAGEMENT
Arthur Kanowitz, MD, Thomas M. Dunn, PhD, NREMT-B, Elyse M. Kanowitz,
5 BA, WilliamW. Dunn, BA, NREMT-P, Kayleen VanBuskirk, BA
ABSTRACT
Objective. To determine the safety and effectiveness of fentanyl
administration for prehospital pain management.
Methods. This was a retrospective chart review of patients transported by
ambulance during 2002–2003 who were administered
fentanyl citrate in an out-of-hospital setting. Pre and post-pain-management
data were abstracted, including
vital signs, verbal numeric pain scale scores, medications administered, and
recovery interventions.
In addition, the emergency department (ED) charts of a subgroup of these
patients
were reviewed for similar data elements.
Results. Of 2,129 patients who received fentanyl for prehospital analgesia,
only
12 (0.6%) had a vital sign abnormality that could have been caused by the
administration of fentanyl. Only one (0.2%) of
the 611 patients who had both field and ED charts reviewed had a vital sign
abnormality that necessitated a recovery intervention.
There were no admissions to the hospital, or patient deaths, attributed to
fentanyl use. There was a statistically
significant improvement in subjective pain scale scores (8.4 to 3.7).
Clinically, this correlates with improvement from
severe to mild pain.
Conclusion. This study showed that fentanyl was effective in decreasing pain
scores without causing
significant hypotension, respiratory depression, hypoxemia, or sedation.
Thus, fentanyl citrate can be used safely and
effectively for pain management in the out-of-hospital arena.
Michael,
I'm glad to see that NY is progressing and that some progress is being made
elsewhere. I'm afraid that it's going to take some retirements and funerals here in
AZ before anything will change.
Gene
Gene Gandy, JD, LP, NREMT-P
My view: If they need analgesia, then they should not be triaged to a BLS unit.
Period.
BTW, the dirty lawyers are beginning to wake up to the lack of pain management in
prehospital care. Beware.
Gene Gandy, JD, LP, NREMT-P
In the case of AZ, I think it's because the same entrenched people have "run" EMS
here for decades. I do know that the AZ State Medical Director, Dr. Bently Bobrow
seems to be somewhat progressive and I hope the situation may change soon.
Thanks for the article. Actually I was aware of it and have it in my archives.
Excellent work.
Gene
Gene Gandy, JD, LP, NREMT-P
Hi
about opioids in emergency setting.
1 - I would like to insiste in the fact that morphine has got the same
efficiency than fentanyl or sufentanil (2 studies in prehospital setting
about this subject Galinski Am J Emerg Med 2005; Bounes Ann Emerg Med
2010 ).
2 - Opioids (morphine) is not the only pain killer which can be use:
paracetamol, NSAI drugs, nitrous oxid can be use togother or with morphine
(multimodal analgesia).
3 - In our country (France) "paramedic teams" which are fire man, do not
have analgesic at all. If a patient is very panfull they call an EMS which
are staffed by an emergency physician and nurse who are going to do
analgesia.
4 - In emergency room, nurses can give morphine following a strict analgesic
protocol before the physician see the patient. But nurses received a
specific formation about morphine. This point is fundamental.
When a patient is very painful, it is very difficult to relieve his pain
without a titration of morphine. We can not know in advance which dose of
morphine is going to be efficient for this patient. And this dose is going
to be different from another patient with the same pathology. This
necessitate a strong formation about morphine because this good and
efficient drug has, as all opioids, side effects one of which is respiratory
depression.
However that may be, over a certain level of pain, the management by an
emergency physician and his team is indispendable. Some time we have to do
sedation or general anesthesia in the field.
Michel Galinski
Centre National de Ressources de lutte contre la Douleur - CNRD.
H�pital Armand Trousseau
26, av Arnold Netter
75571 Paris cedex 12
Secretariat: 01 44 73 54 21
Site internet: www.cnrd.fr
Hi
I would like to make an important precision about opioids.
Of course fentanyl is efficient for pain relief . It is a powerful analgesic
as sufentanil. The question was not there.
The questions is :
Is morphine less powerful than fentanyl or sufentanil ?
A recent study compared sufentanil and morphine in prehospital setting
(Bounes et al Ann Emerg Med 2010 [epub ahead of print] .
This controlled, randomised and double blind trial (108 patiens included)
showed 2 importants thing:
in the first 15 minutes of titration (measurement of pain intensity each
3 min), sufentanil group obtained a better score than morphine group at
time 9 min only. This is logical because the sufentanil onset of action is
shorter than morphine one (2 minutes vs 5 min). At time 12 minutes, there
was a steady state between the 2 groups, no difference at T12 and T 15
minutes.
The followup of patients during 6 hours showed clearly that the
morphine duration of action was superior than sufentanil one. During the
first 6 h, 32% of morphine group was administered analgesic medication
versus 51% in the sufentanil group.
Conclusion: this study confirm the results about previous study fentanyl
(same family of opioid that sufentanil) in prehospital setting; morphine has
the same efficiency than sufentanil but its duration of action is longer
(which it is not a surprise).
The message is that the opioid nature it is not the problem. The problem is
the possibility to use it when it is necessary and to use it in good
conditions. The side effects of fentanyl, sufentanil or morphine are the
same. Titration is the best way to find the best dose.
Michel Galinski
Centre National de Ressources de lutte contre la Douleur - CNRD.
H�pital Armand Trousseau
26, av Arnold Netter
75571 Paris cedex 12
Secretariat: 01 44 73 54 21
Site internet: www.cnrd.fr
Dr. Isenberg's question is vital. Do you have policy for which patients go ALS vs.
BLS? I do and need for perenteral pain management is ALS.
Keith Wesley, MD
Medical Director
HealthEast Medical Transportation
St. Paul, MN
Keith,
What are the pain management options for BLS services? Or, from a
policy development perspective, what SHOULD the options be for a BLS
service?
This brings to mind the various non-pharmacologic methods that you and
others have mentioned in earlier posts. Should these non-pharmacologic
methods get more attention even from ALS providers? I'm thinking about
cold packs, positioning, transcutaneous electronic nerve stimulators
(TENS), audio analgesia, guided imagery, etc.
I'm also wondering what the feelings are from the group for use of 50%
nitrous oxide / 50% oxygen mixtures by BLS crews (assuming appropriate
protocols and training).
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
(Re-posted on behalf of Michael Daliey [to keep the entire discussion
within the same thread])
Great question Art. Frankly, pain management should not alter a
neurologic exam if titrated appropriately. Gentle and judicious,
improvement of discomfort, rather than a goal of removal of all pain.
Some other postings have commented on protocols for opiate
administration rather than fixed doses, and giving the medication the
patient requires for pain. With guidance from a weight based dosing,
this may be the best way to go. May there be a case that the pain is
needed for diagnosis? Perhaps. But if you use a short acting agent
like fentanyl, in most cases the medication will be wearing off prior
to the physician getting to the bedside.
Michael W. Dailey, MD FACEP
Director of Prehospital Care and Education
Associate Professor of Emergency Medicine
Albany Medical Center
518/ 262-3773
Hello!
My name is Erik and I am new to the discussion group. I have been in the
Pennsylania Emergency Medical Services for twenty-three years with the last
seventeen years as a Nationally Registered Paramedic. I am very interested
in learning about the constant changes that are occuring in pre-hospital
medicine.
I am happy that pain management has become a priority in the pre-hospital
management of a patient even though it was way overdue. However, I think the
biggest issue that faces pre-hospital providers are the "drug-seekers" and
the concern of an Emergency Room physician/nurse saying "oh this guy is a
drug-seeker how did you fall for that?"
Unfortunately, people who frequently abuse the system will create
stereotypes and fear which results in hesitation on performing pain
management. My question is how do we train our younger providers,
physicians, and nurses to overcome this stereotype and at the same time
recognize someone who is abusing the systems and is attempting to feed into
an addiction?
Erik Davis AS, NREMT-P
Mercy Health Systems
Philadelphia, Pennsylvania
Dr. Isenberg's concern about patient's needing pain management and being
triaged to BLS is a valid concern.
Personally, I think that it is a way of thinking that needs to be changed
both with the BLS and ALS providers. Currently, in our system the BLS
provider is typically dispatched alone for fractures/pain type emergencies.
After arriving on location, they perform the necessary Basic Life Support
skills and then transport the patient. One way to correct this issue is to
change their way of thinking via training. Let's teach the Emergency
Medical Technicians on how to evaluate the severity of pain and determine
the necessity of pain management. Simultaneously, we need to change the
thinking of Paramedics. There is a belief with some Paramedics that "well,
by the time they dispatch me and I get there they could be at the
hospital." I think this type of mentality/behavior needs to change for pain
management to be truly effective.
Erik Davis AS, NREMT-P
Mercy Health Systems
Philadelphia, Pennsylvania
You're right, but it's also about changing the thinking ABOUT BLS and ALS
providers.
For example, it's hard to insist on all-volunteer EMT services [to cut costs], and at
the same time add responsibilities and training requirements associated with
medication administration. In addition, the CQI process for all those calls needs to
be in place. If the person accomplishing the CQI process is donating his/her time,
and the EMTs are volunteer, what kind of service do you expect?
Don't get me wrong, I have the utmost respect for those volunteering their time to
train and practice out-of-hospital medicine. We have momentum now, increasing
the professionalism and standardization of training for EMS providers. We need to
advocate for their remuneration.
Carin M. Van Gelder, MD FACEP FAAEM
EMS Medical Director, NHSHP
Assistant Professor, Dept of Emergency Medicine
Yale University School of Medicine
ph (203) 785-6159
c (203) 627-7414
f (203) 785-3196
Is this still an issue--concerns that analgesics will blunt the exam? Most
abdominal and surgical emergencies are diagnosed with CT or ultrasound. The
patient's mentation plays a decreasing role.
Bryan
-Bryan E. Bledsoe, DO, FACEP, FAAEM
Clinical Professor of Emergency Medicine
University of Nevada School of Medicine
Attending Emergency Physician
University Medical Center of Southern Nevada
Medical Director, MedicWest Ambulance
Las Vegas, Nevada
Erik has hit one of the crucial points. Simply put, drug seekers do not use 9-1-1.
They don't want a shot, they want a prescription. I remember an article awhile back
about Headache patients and EMS. Headache patients are a frequent source of drug
seekers but this article showed that patients with a compliant of headache that came
by EMS were almost always sick and had a real need for evaluation and care.
Interestingly, the current edition of the Carolyn AAOS Paramedic text devoted 2
pages to identifying drug seekers. This is not appropriate. No more than blowing
someone off with a complaint of chest pain because you just don't believe them.
Keith Wesley,MD
Mic is absolutely correct in that pain control is not always a drug. As with many
things in EMS, ALS has forgotten that basic skills provide the majority of care.
I would never advocate for a single BLS service to institute an ALS intercept simply
to treat pain. Dispatch is the best time to determine whether or not the condition is
one that merits pain control and then send ALS.
In the absence of ALS, or more specifically, in combination with ALS the basic skills
of rest, ice, compression, and elevation work wonders. Not to mention providing a
calming assurance that their pain will be addressed and get better.
As for nitrous? I'm all for it. The UK and Australia have shown that this is a valuable
tool for the BLS provider. We just have to get the damn FDA to understand this and
to approve the agents they are using for use here in the States.
Keith Wesley, MD
Medical Director
HealthEast Transportation
St. Paul, MN
Dear Dialog readers,
The beauty of this dialog is to inform each other of situations and
current practices which others may not be aware of. A previous
contributor suggested drug seekers do NOT dial 9-1-1. I wish that was
true for my EMS providers.
In Alaska there are vast areas where no pharmacies exist and our
volunteer EMS providers are quite fatigued and demoralized from drug
abusers calling 9-1-1. Many drug seekers have been cut off from the few
existing clinics with dispensaries and ER's, leaving 9-1-1 the only
access to a quick fix when other avenues dry up. There are various
manipulations and scenarios which these patients devise and I cannot
expect a volunteer EMS person to judge whether or not to give Morphine
and then transport to the nearest hospital which can be 100 miles away.
When a citizen takes a day off from paid employment to respond to one of
these calls, it sucks a their will to provide community service.
TWO articles are worth review:
1. CDC MMWR report (59:32 1026) "The number of poisoning deaths from
opiates (1997=4000 deaths 2007=14,500 deaths)"
2. CDC MMWR report (59 (30);957 Death Rates for the three leading
causes of Injury Death" in which deaths from MVA and firearms has
dropped but death from drugs is on exponential rise.
My next email will separately discuss the use of multiple controlled
substances in volunteer or rural EMS agencies.
Danita Koehler, MD
Chief, EMS
US Army- Alaska
Several years ago I was on a prehospital pain management panel at the
University of Western Australia. They were making significant progress in
switching to ketamine for many painful conditions--especially trauma. Has
anybody had much prehospital experience with using ketamine in the States?
Bryan
-Bryan E. Bledsoe, DO, FACEP, FAAEM
Clinical Professor of Emergency Medicine
University of Nevada School of Medicine
Attending Emergency Physician
Medical Director, MedicWest Ambulance
University Medical Center of Southern Nevada
Las Vegas, Nevada
My Take:
Pain management starts with stress reduction and visa versa. One
common modality that is often overlooked is the use of an ice/cold
pack. For musculosckeletal injuries, this is often my primary
treatment.
I believe that, in general, all [prehospital] healthcare providers,
including myself are poor providers of pain management. As mentioned
by the others here, this is all-to-often as a result of those whom
inappropriately seek pain management. Also, not trusting the
patient's representation of the severity of pain. Both should have no
baring in the back of an ambulance.
Maybe the paramedicine curriculum has changed, but I don't remember
the part of the text book that mentions drug addiction as a
contraindication to pain management. Dr Bledsoe?
Withdrawal symptoms may be worse than overdose symptoms right? Well
they are most definitely worse than the symptoms that will present
after a therapeutic level of pain relief is reached. The most common
symptom there is PAIN RELIEF.
Drug seeker = someone still in pain.
Not that every one deemed a drug seeker really is, but lets consider
the consequences of providing them with what they want. Many who fall
victim to opiod/opiate addiction do so because of an initial symptom
of pain. They found relief with the drugs, and found pain when they
stopped taking them. So when they present to EMS with a complaint of
pain, they probably have pain. Yes, it may be pain due to the falling
levels of narcotic within their body, but do you know that? More
importantly, do you care? They are in pain, and we can treat pain.
This is an extreme argument I know. The argument against this could
be a straw man built on the basis that this would lead to an EMS pain
relief dependancy, or contribution to the problem. Until us
paramedics are taught differently, shouldn't we do what we are
taught? The complaint is real unless proven otherwise.
If we are in the practice of following the evidence, than we obviously
need to rethink the way we withhold pain management. And by
'rethink', I mean 'omit'.
Consider the following:
If epinephrine was a schedule one narcotic that was commonly abused,
would you withhold it if an "epi-abuser" presented with anaphylaxis?
The drug abuser is often in more pain than the patient who has never
had an opiate in their system. We aren't handing out prescriptions or
giving large doses, we are just getting them to the hospital.
This is just my point-of-view and I am aware of the holes. Nothing is
absolute and this is no exception.
Adam Thompson, EMT-P
Lee County EMS
EMS Educator - Edison State College
Paramedicine101.com
EMSresponder.com
Lee County, Florida
Dr. Wesley,
Presuming that article was based on evidence, do you remember the
title of the study? That would be an abstract worth reading. How do
we fix the problem that is subpar pain management by utilizing
evidence? Do we obtain tox-screens on all non-recipients of pain
management, and use those results to quantify the prehospital
provider's ability to judge who is or is not a drug seeker? I
actually think that is an idea worth looking in to, but more-so I
think taking your approach may lead to an improved level of care.
Consider the patient complaining of pain to truly be in pain until
proven otherwise.
As for the sub-standard state guidelines for prehospital pain
management go, that is very unfortunate. I would like to hear that
there is a change in the works. I have also heard of restrictive
protocols that only allow the paramedic to administer certain pain
therapies after receiving online medical direction. I have heard many
stories of systems like this, and the paramedics within them becoming
discouraged after continually being refused when attempting to obtain
valid orders. Is anyone aware of any research done on systems like
these? Does anyone work in one of these systems?
Adam Thompson, EMT-P
Lee County EMS
EMS Educator - Edison State College
Paramedicine101.com
EMSresponder.com
Lee County, Florida
Thirty years ago many services in Texas were using Nitronox (50% nitrous/50%
oxygen) but the cost of the rig was high, and abuse among EMTs and others was
high (I knew one boozing fire chief who would get his Nitronox fix first thing every
morning). Eventually use tapered off. That's too bad, because I think it's an
appropriate method for basic EMTs to use.
The reason for the expense is that there must be a regulator that will shut the
nitrous off if the oxygen runs out, and that's apparently somewhat more expensive
than an oxygen regulator.
My information may be old like me. I haven't looked into the currently available
rigs.
Gene
Gene Gandy, JD, LP, NREMT-P
Dr. Bledsoe,
I rarely still have this issue, though it is still often preached as a
current problem. If it is a problem, why don't the physicians that
have this concern teach their paramedics how to perform and document a
good physical exam? They would have their baseline findings and a
patient with some pain relief.
Because I am interested in your take in particular, regarding many of
the issues stated thus far within this discussion, what would you
consider realistic solutions to these problems?
Adam Thompson, EMT-P
Lee County EMS
EMS Educator - Edison State College
Paramedicine101.com
EMSresponder.com
Lee County, Florida
We should not get hung up too much on so called drug seekers. It is not the patient's
job to prove they are in pain. Prehospital providers should treat pain as appropriate
and not try to determine who is real and who is not.
Derek
Derek Isenberg, MD, NREMT-P
Medical Director
Mercy EMS
Mercy Catholic Medical Center
Department of Emergency Medicine
501 South 54th Street
Philadelphia, PA 19143
215.748.9740
215.748.9208 (fax)
Maybe I should clarify:
Often this triage is done at the EMD level rather than by providers. I hope that most
ALS providers would recognize when I patient needs pain medications and should
be given parenteral medications. In many EMS systems, only a BLS unit would be
dispatched to a fall without major mechanism. For example, only a BLS unit would
be dispatched injuries such as a hip fracture after a slip and fall or a child with a
wrist fracture after a fall off the jungle gym
Derek Isenberg, MD, NREMT-P
Medical Director
Mercy EMS
Mercy Catholic Medical Center
Department of Emergency Medicine
501 South 54th Street
Philadelphia, PA 19143
215.748.9740
215.748.9208 (fax)
The term "drug seeker" should not even be in a prehospital provider's vocabulary.
Our job is not to judge but to treat and relieve pain. Even chronic drug users may
have breakthrough pain, drug abusers may have legitimate pain issues, and it is not
within either the training nor scope of practice of paramedics to do social
evaluations of people complaining of pain in the field.
Some while back, we had a similar conversation about the use of ammonia capsules
to "awaken" patients who were thought to be malingering. This has no place in EMS
either. I have seen medics and doctors revel in recounting how they "punished" a
patient they thought was faking. This is abhorrent to medicine.
I also know of at least one instance where an EMS service had to pay out $$$
because an ammonia cap was placed under a non-rebreather mask and left on the
patient's face. It burned a hole in her skin that had to have skin grafts.
Gene Gandy, JD, LP, NREMT-P
Derek,
My take is this: If dispatch knows that there is a probable fracture, then it ought to
also know that major pain is going to be involved, and an ALS unit should be
dispatched.
It's been years since I moved a routine hip fractured patient without having
analgesia on board. There's no need for it, and to do otherwise is barbaric. Yet,
many systems send BLS people who cannot give analgesia, and they move patients
and cause them horrific pain. That's just wrong.
When will the medical community (read doctors) wake up to the fact that we're not
doing adequate pain management in the field, and step up and do something about
it? Never, I fear, because there's no money in it. And there's so much cultural crap
that leads medical providers to want to punish patients for expressing pain.
When systems build in dispatch protocols that ensure that patients with pain
management issues will be handled inappropriately, whose fault is that?
Well, it all comes back to who actually runs EMS. It ought to be the physicians, but
it mostly isn't. It's managers with MBAs and business degrees. Sad.
Gene Gandy, JD, LP, NREMT-P
I'm wondering what members of this list think about this scenario: Trauma patient
who has significant pain and requires cspine precautions/packaging on a long
board. The BLS non-transport unit does not immobilize due to the degree of pain
and waits for ALS to arrive to administer pain meds prior to immobilization and
transfer to the transport vehicle. Alternatively, ALS is on-scene first and opts to
treat pain prior to immobilization & transfer to their transport vehicle. This
typically involves initiation of an IV and titration of pain meds (narcotics) and
potentially delays transports/prolongs scene time by 10-20 minutes. In my
experience, ALS scene times are greatly reduced when the trauma patient is
packeged prior to their arrival. Presumably, EMS opts to do this selectively on
patients who do not appear to have immediatly life-threatening injuries.
1. Is this reasonable patient care?
2. Can BLS personnel reliably identify trauma patients who are unstable or
potentially unstable?
3. Can ALS personnel reliably identify trauma patients who are unstable or
potentially unstable?
4. What objective data or outcome measure could be used to help identify patients
where this practice is undesirable?
DTK
David T. Kim, M.D., FACEP
Idaho Emergency Physicians, P.A.
Life Flight Network
Boise, ID
How much ketamine are they using? My only experience with ketamine is with ED
procedural sedation (4m/kg IM or 1m/kg IV). At these procedural sedation doses,
your ability to examine the patient and obtain a history is nil and it may take over an
hour for the effects of ketamine to wane. I don't see how ketamine will fit into the
prehospital arena, at least at procedural sedation doses.
DTK
David T. Kim, M.D., FACEP
Idaho Emergency Physicians, P.A.
Life Flight Network
Boise, ID
I’m on the road do not have access to the medical school library to download
the papers with the dosage specifications. Below are two of the abstracts.
Bryan
-Bryan E. Bledsoe, DO, FACEP, FAAEM
Clinical Professor of Emergency Medicine
University of Nevada School of Medicine
Attending Emergency Physician
University Medical Center of Southern Nevada
Las Vegas, Nevada
Pre-hospital use of ketamine for analgesia and procedural sedation.
London Helicopter Emergency Medical Service, Department of Pre-hospital
Care, The Royal London Hospital, London E1 1BB, UK.
Comment in:
* Emerg Med J. 2009 Oct;26(10):760-1.
<http://www.ncbi.nlm.nih.gov/pubmed/19773515>
Abstract
The safe delivery of adequate analgesia and appropriate sedation is a
priority in prehospital care. The use of ketamine is described for analgesia
and sedation in 1030 trauma patients in a physician-led prehospital trauma
service. Ketamine was mainly used in awake non-trapped patients with blunt
trauma for procedural sedation and analgesia. Detailed database searches did
not demonstrate loss of airway, oxygen desaturation or clinically
significant emergence reactions after ketamine administration. Ketamine is
relatively safe when used by physicians in prehospital trauma care.
Am J Emerg Med. <javascript:AL_get(this, 'jour', 'Am J Emerg Med.');> 2007
Oct;25(8):977-80.
Ketamine for prehospital use: new look at an old drug.
Svenson JE
<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Svenson%20JE%22%5BAuthor
%5D> ,
Abernathy MK
<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Abernathy%20MK%22%5BAut
hor%5D> .
Section of Emergency Medicine, University of Wisconsin, Madison, WI 53792,
USA. j...@medicine.wisc.edu
Abstract
INTRODUCTION: Ketamine has been used extensively for analgesia and
anesthesia in many situations, including disaster surgery where extra
personnel and advanced monitoring are not available. There are many features
of ketamine that seem to make it an ideal drug for prehospital use. The
reported use of ketamine in the prehospital environment is limited, however.
The purpose of this study is to review the experience in the use of ketamine
in a regional air ambulance service and suggest indications for its use in
the prehospital setting.
METHODS: This was a retrospective study of all patients transported by a
regional aeromedical program. Patients were included in this study if the
crew had used ketamine at any time during the flight. Data regarding the
transport collected included patient age, type of transport, indications for
ketamine use, and adverse reactions.
RESULTS: During the period studied, ketamine was used in 40 patients. The
age range was 2 months to 75 years. The indications and situations requiring
use were varied and included both trauma and medical patients. Hypotension
with need for analgesia, agitation or combativeness and intact airway, or
pain unresponsive to narcotic medications were the most common indications
for use. Ketamine was used both intravenous and intramuscular, even without
intravenous access. There were no adverse reactions.
CONCLUSIONS: Ketamine is an ideal drug for use in many prehospital
situations. Our experience suggests that it is safe, effective, and may be
more appropriate than drugs currently used by prehospital providers.
(Re-posted on Behalf of Charles Krin {to keep the discussion within
the same thread])
There is another problem with Nitronox rigs- the problem with scavenging the
waste gases, the same problem that has caused Nitrous to go out of favor among
dentists, despite 'laughing gas' being one of the best, and safest, dental analgesics
known to humanity.
If waste gases are a problem in a 1000 plus square foot (figure 10 foot high ceilings,
so 10,000 cubic feet) dental office with at least 5 changes of air per hour, how much
more dangerous would it be in the back of a Type II or III ambulance, with maybe
100 cubic feet of space, especially during weather extremes, when ventilation of the
rig may be limited?
Admittedly, in a moving ambulance, a scavenging system with an overboard dump
is much simpler than in a fixed, often multi-office building. IIRC, the problem wasn't
only with the 'laughing' effects on the dentist and techs, but there was also concern
about long term effects, especially on pregnant females. Again, EMS would have the
advantage of generally shorter periods of use.
as far as the need for a specialized regulator, it appears that Entonox/Nitronox can
actually be stored in a single tank- from Wiki (yes, I know, not the best reference,
but a quick one):
The gas is made of a mixture of fifty percent _nitrous oxide_
(http://en.wikipedia.org/wiki/Nitrous_oxide) (N2O or laughing gas)
and fifty percent _oxygen_ (http://en.wikipedia.org/wiki/Oxygen) (O2). The ability
to combine _nitrous oxide_ (http://en.wikipedia.org/wiki/Nitrous_oxide) and
oxygen at high pressure while remaining in the gaseous form is due to the
_Poynting effect_ (http://en.wikipedia.org/wiki/Poynting_effect) (after _John
Henry Poynting_ (http://en.wikipedia.org/wiki/John_Henry_Poynting) , an
English physicist).
The Poynting effect involves the dissolution of gaseous O2 when
bubbled through liquid N2O, with vaporisation of the liquid to form a gaseous
O2/N2O mixture.
Inhalation of pure nitrous oxide over a continued period would render a human
_hypoxic_ (http://en.wikipedia.org/wiki/Hypoxia_(medical)) , and the 50% oxygen
content prevents this from occurring. The two gases will separate at low
temperatures (<4 _°C_ (http://en.wikipedia.org/wiki/Celsius) ), which
would permit administration of hypoxic mixtures. Therefore, it is
not given from a cold cylinder without being shaken (usually by cylinder
inversion) to remix the gases.
That being said, and given scavenging capability, I agree with Mr. Gandy
that Nitronox would be potentially be a very safe analgesic to add to
the capabilities of EMT Basics. It is even safer if the patient has one
hand free, and can cooperate with therapy:
The gas is self administered though a _demand valve_
(http://en.wikipedia.org/wiki/Demand_valve) , using a mouthpiece, bite block or
face mask. Self-administration of Entonox remains safe because if enough is inhaled
to start to induce anaesthesia, the patient becomes unable to hold the valve, and so
will drop it and soon exhale the residual gas. This means, that unlike with other
anesthetic gases, it does not require the presence of an _anaesthetist_
(http://en.wikipedia.org/wiki/Anesthesiologist) for administration.
The 50% oxygen in Entonox ensures the patient will have sufficient oxygen in their
system for a short period of _apnoea_ (http://en.wikipedia.org/wiki/Apnoea) to be
safe.
Additionally, the rapid onset (30 seconds) and rapid dissipation of effects (60
seconds) adds to the safety profile. Most of the other dangers of the gas involve
longer term use, at anesthetic, rather than analgesic, levels.
To the best of my knowledge, unlike opiods, there is no histamine
release, and no one is allergic to this drug.
So, beyond medical and legal inertia, and the complaints of
ambulance companies at the initial costs of installation, is there any reason
why we can not urge our respective systems to allow our EMT-Bs and Paramedics
to offer this simple method of pain relief?
Charles S. Krin, DO (ret)
EMS author and instructor, retired FP/EP.
(Re-posted on behalf of Craig McMillan [to keep the discussion in the
same thread])
Entonox (50% nitrous 50% oxygen) is readily available in New Zealand
and is the primary means of pain relief for BLS providers there. It is
available in a wide variety of tank sizes with a demand regulator
similar to a SCBA tank.
In my experience it is a safe and effective form of pain relief for a
wide variety of patients, the only issue is that the tanks need to be
shaken prior to use as the gases tend to separate especially in cold
weather.
Craig McMillan
Former Kiwi, current American
Dr. Kim,
I will weigh in on your four questions.
1. I believe it is reasonable to initiate IV access and administer analgesia prior to
moving a patient who has suspected fractures or is in a great deal of pain. I see this
all the time especially when extrication is involved. Fentanyl is administered and
then followed by Etomidate and the patient is moved while sedated. I don't know
why this can't become the norm and not the exception of tangled patients.
2. I would certainly hope so. If they cannot, after multiple hours of training and
multiple merit badge courses, then we need to go back to the drawing board on
education standards. I have seen just the opposite. Too often, EMS personnel lean
way to far to the "potentially unstable" side...and I cite the number of patients who
are flown instead of ground-pounded (or run emergency to the ED) and then are
released in a few short hours after arriving at the hospital. I have not seen any EMS
personnel that would err to the side of delaying on scene care to provide analgesia
on patients who could potentially be unstable.
3. See #2 only more so.
4. Now this is the core piece of the puzzle. The only issue is that with trauma, there
are a number of variables that have nothing to do with the condition of the patient
that may or may not make analgesia or sedation prior to moving or packaging the
patient desirable. It isn't just what data or outcomes, we have to include the other
mitigating factors (location of patient, entanglement, scene security, etc) as well.
Thanks for the time,
Dudley Wait
Schertz EMS
I would also like to point out that fentanyl can be given IN as well without IV access.
This is perfect for a child with a broken arm who just needs a "sniff" of medication
for comfort and not the torture of the IV. IN fentanyl is also great for trauma where
IV access may delay care and arguably worsen outcomes.
Derek Isenberg, MD, NREMT-P
Medical Director
Mercy EMS
Mercy Catholic Medical Center
Department of Emergency Medicine
501 South 54th Street
Philadelphia, PA 19143
215.748.9740
215.748.9208 (fax)
The first paper used an analgesic dose of 0.1 mg/kg IV and 1 mg/kg IM.
The second paper used an analgesic dose of 1 mg/kg IV and 5 mg/kg IM.
Quite the difference between the 2 dosages.
Fred Wu
Kaweah Delta Medical Center
I found the study.
Prehosp Emerg Care. 1998 Oct-Dec;2(4):304-7.
Emergency medical services transport of patients with headache: mode of arrival
may indicate serious etiology.
Nemer JA, Tallick SA, O'Connor RE, Reese CL.
Department of Emergency Medicine, University of Pittsburgh School of Medicine,
Pennsylvania, USA.
Abstract
OBJECTIVE: To determine whether mode of arrival is associated with seriousness of
etiology and use of diagnostic testing in patients treated in the emergency
department for headache.
METHODS: This observational, retrospective study was conducted by consecutive
review of the records of patients presenting to the emergency department with a
chief complaint of headache from December 1994 through May 1995. Patients with
altered mental status or seizures were excluded. Mode of arrival was classified as
either by EMS or other (e.g., private vehicle). Patients with a final diagnosis of
meningitis, intracranial hemorrhage, or central nervous system tumor were
classified as having serious causes, whereas those with headache due to migraine,
tension headache, or headache that was otherwise unspecified were classified as
nonserious. The use of diagnostic studies, such as lumbar puncture or CT scan, and
their results, was recorded. Patients were included in the category of patients
having serious intracranial pathology even if the diagnosis was delayed. Statistical
analysis was performed using the Yates-corrected chi-square test, and by
determining odds ratios (ORs) with 95% confidence intervals.
RESULTS: For 967 patients presenting with a chief complaint of headache, 837
charts were included in the analysis. A total of 102 patients arrived by EMS, and 735
arrived by other means. Patients arriving by EMS had a higher rate of serious cause
of headache than did those arriving by other means (OR = 18.5, p < 0.0001). EMS
patients tended to undergo additional diagnostic testing (OR = 4.4, p < 0.0001), and
those tests were more likely to be abnormal than for those arriving by other means
(OR = 9.4, p < 0.0001). Males had a somewhat higher rate of serious diagnosis (OR =
2.6, p < 0.05).
CONCLUSIONS: In this EMS system, patients with headache who arrive by EMS are
more likely to have serious causes. Mode of arrival may be of use to the clinician in
assessing risk of serious illness among patients with headache. Whether this
observation represents an element of self-triage or a combination of other factors
remains to be determined.
With that said. I'd like to see the numbers from our colleague in Alaska. If there are
that many "frequent flyers" causing problems then perhaps something needs to be
addressed locally as Tarrant County did.
http://www.wfaa.com/news/local/Tarrant-ambulance-service-reaches-out-...
Keith Wesley, MD
Hello Mic!
Any chance of uploading this article for download?
DTK
David T. Kim, M.D., FACEP
Idaho Emergency Physicians, P.A.
Life Flight Network
Boise, ID
Thank you, Dr. Wu for providing a copy of the article by Svensen & Abernathy
(American Journal of Emergency Medicine (2007) 25, 977–980). I believe Mic
Gunderson will be posting a copy for download on the dialog resource page.
As noted in the previous email below, procedural sedation doses were used in this
study and were administered by an air medical program with a physician-nurse
crew configuration. Although the use of ketamine was considered safe and effective,
there was no data provided on the impact of ketamine on the patient's course at the
receiving facility. The discussion section (see excerpt immediately below) discusses
duration of action and attempts to minimize the potential impact on the ED
evaluation but I'm extremely skeptical based on my personal experience with
ketamine in the ED. Although ketamine was given by a physician in this study, the
authors assert that ketamine can be safely given by non-physicians and back this
statement up by providing a single reference that I have not read: Porter K.
Ketamine in prehospital care. Emerg Med J 2004;21:351 - 4.
I've not seen the other paper either but the abstract below makes one wonder about
the meaning of "relatively safe"!
DTK
"Ketamine induces the analgesic and dissociative state
within 60 seconds after a single IV dose and within 3 to
5 minutes for an IM dose. This sedation lasts approximately
10 to 15 minutes for IV doses and 20 to 30 minutes for IM
doses [15]. These kinetics have both advantages and
disadvantages for prehospital care. First, the duration of
analgesia and anesthesia are long enough for many transports,
and so, the patient is not overly sedated or dissociated
on arrival in the emergency department and can be
adequately examined by the staff. On the other hand, the
duration is short enough that repeated doses may be
necessary."
David T. Kim, M.D., FACEP
Idaho Emergency Physicians, P.A.
Life Flight Network
Boise, ID
Hi
In France we have a prehospital emergency system has 2 level:
first level fire man for BLS (as paramedic). They do not have medication.
Second level ambulance with emergency physician and nurse
If fire man are front of a painful patient (trauma for example) and they can not
move him, they call the second level.
So we can do every kind of treatment from simple analgesia to anaesthesia.
- For a trauma patient for example, we begin with titrated morphine:0,1mg/kg IV
then 3 mg every each 5 minute; Goal: VAS or NRS = or< 3/10; no maximum dose.
Limitation are side effects (nausea, vomiting, apnea). for the mobilisation we add
nitrous oxide. The onset of action is 5 minutes so we have to wait 5 minutes before
the patient mobilisation. The advantage with morphine is that there is an antidote
(naloxone).
If we can not move the patient without pain after this stratégy , we add ketamine,
moderate dose : 0,5 to 1 mg/kg iv.
We never use etomidate in this situation because there is a risk of apnea. Etomidate
is for anesthesia.
The advantage of this system is the diagnosis and the efficient treatment can be
done by emergency physician in setting. And after that the patient could be lead to
the appropriate place.
Michel Galinski
CNRD
Centre National de Ressources de lutte contre la Douleur
Hôpital Armand Trousseau
26, av Arnold Netter
75571 Paris Cédex 12
Tel :
+33 144735426
Secrétariat: +33 144735421
Hi
About ketamine
there is 3 kind of use of ketamine
1 - low dose (0,1 to 0,5 mg/kg, IV) for its antihyperalgesic effect. It is in use with
morphine as an adjuvant. A study showed that ketamine associated to titrated
morphine reduced the consumption of morphine versus titrated morphine and
placebo (- 26%). But no difference for pain relief.(Galinski et al Am J Emerg Med
2007). For this dose more studies in prehospital setting are necessary because the
advantages are not very clear
2 - Moderate dose, Doses between 0,5 and 1,5 mg/kg (could be titrated) : this
moderate dose is used for procedural pain : We use this dose when a patient is still
very painful in spite of titrated morphine. Or when we could not have an access to
patients airway (incarcerated patient). The advantage of the ketamine in a such
situation is that the patient keeps a spontaneous ventilation and blood pressure is
not alterated.
3 - High dose, Doses between 2 to 3 mg/kg IV are for anaesthesia.
Michel Galinski
CNRD
Centre National de Ressources de lutte contre la Douleur
Hôpital Armand Trousseau
26, av Arnold Netter
75571 Paris Cédex 12
Tel :
+33 144735426
Secrétariat: +33 144735421
Yes, Yes, and Yes,
If it is a patient meeting your Major Trauma criteria (see CDC new guideline) then it
is not appropriate to delay transfer for the reasons you stated
Keith Wesley, MD
There are now several articles posted on the resource page for this
topic at http://groups.google.com/group/naemsp-dialog/web/topic-4--prehospita....
One of our objectives here is to provide a collection of resources
useful to everyone researching the topic of prehospital pain
management. If you have links, files, etc. that you think should be
included, please send them to me at mic.gunder...@gmail.com.
Thanks,
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
I know I'm jumping in here a little late, but not only do I think that
parenteral pain management means ALS, but I think it's one significant
argument for the existence of ALS EMS. Think about what proportion of our
patients present with some type of pain versus what proportion presents with
the most studied prehospital complaint--cardiac arrest. Has anyone studied
the quality of pain management as a key performance measure for an ALS (or
BLS, for that matter) EMS system? Admittedly, pain management doesn't
usually appear to influence mortality like cardiac arrest or STEMI
management, but is it not as "worthy" a KPI? I think that every patient in
pain would think so!
Laurie
Laurie A. Romig, MD, FACEP
Medical Director
Pinellas County EMS
Hi again to all,
I would like to hear thoughts regarding regional anaesthesia in the prehospital
setting. In New South Wales we have had small groups of specially trained
advanced paramedics exploring regional nerve blocks over recent times with good
results to date. Paramedic-performed digital blocks for fractured/dislocated fingers
have proven very effective and safe, reducing the need to fill the patient with
systemic opioids. We also have a randomised controlled trial underway comparing
paramedic-performed fascia iliaca compartment block to standard opiate analgesia
in patients with suspected femoral fractures. Results are very positive so far, no
complications or adverse effects identified by trial governance to date. Lots of
potential here, particularly in cases involving prolonged care and also in the elderly
with fracture NOFs, for whom high doses of opiates may be undesirable. The clinical
trial is registered with the Australian New Zealand Clinical Trials Registry for those
interested in further details.
Regards
Paul Simpson
Paramedic Research Fellow/Intensive Care Paramedic,
Ambulance Research Institute
Ambulance Service of New South Wales
0429 129 908 / 9779 3858
Dr. Talbot,
Maybe I am misunderstanding what you wrote - Are you stating that you
require that your paramedics justify NOT giving pain medicine to
patients?
If that is the case, that is excellent. Too many places put too many
unrealistic and unnecessary restrictions on treatment of prehospital
pain.
Tim Noonan.
http://roguemedic.com/
Laurie,
Well said. I completely agree. Pain is the most common complaint in EMS and
in my experience most patients satisfaction is based more on whether or not
their pain was treated then whether or not the field "diagnosis" was
correct, what was the paramedics interpretation of the EKG, or how thorough
an exam was completed by the paramedic.
I am considering doing a statewide CQI study using pain management data
points (Initial and Final Pain Scores and treatment with opioids or other
treatment modalities) as key performance indicators, to look at how well we
treat pain statewide. It would be interesting to compare those regions of
the state without ALS to those with ALS. I certainly believe that every EMS
patient deserves pain management as early as possible. The question will be
how to facilitate pain management in those rural areas that just DO NOT have
ALS.
This is such an important topic and I thank all of you who are involved in
this discussion. Hopefully, by sharing these discussions we can dispel many
of the myths and help improve pain management in EMS worldwide.
Arthur Kanowitz MD FACEP
State Medical Director
Emergency Medical and Trauma Services Section
Health Facilities and Emergency Medical Services Division
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver. Colorado 80246-1530
office 303 692-2984
mobile 720 641-3540
There is a paper on misidentifying drug seekers that I sent to Mic
Truth hurts.
Veysman BD.
Acad Emerg Med. 2009 Apr;16(4):367-8. Epub 2009 Mar 6. No abstract
available.
PMID: 19298618 [PubMed - indexed for MEDLINE]
> Many of the people we care for are having nausea and are experiencing fear along
with their pain. It would be nice to hear what people thing about managing mixed
manifestations of suffering.
There should not be a need for anti-nausea medication for most
patients, but there is a discussion of giving diphenhydramine with
morphine in this podcast at EMCrit
Dr. Edward Gentile talking about the very aggressive morphine protocol
they use without problems:
http://blog.emcrit.org/podcasts/gentile-pain/
The follow-up post explaining the routine use of diphenhydramine:
http://blog.emcrit.org/blogpost/comments-on-pain-protocol/
> As we expand our pharmaceutical options in this domain the issue of drug
diversion and the addicted clinician arise. It would be interesting to hear about
systems to make sure medications go into patient veins not provider veins.
It amazes me that I have never been asked to take a urine drug test,
other than as part of standard pre-employment testing.
I generally give doses of morphine over 20 mg/fentanyl over 200 mcg a
couple of times per year. I have track marks (although they are from
frequent platelet donations). I am regularly questioned about the need
for such large doses of morphine/fentanyl. Doctors act as if they are
doing ME a favor by allowing me to appropriately treat my patient's
pain. If they are truly concerned that this is too much, why has
nobody ever expressed any concern about diversion? I have joked with
my boss, that if I ever come in with my whole body shaved, he should
be suspicious (the visible parts - get your minds out of the gutter).
Tim Noonan.
http://roguemedic.com/
> I see the issue breaking down into the following areas
> 1. Appreciation for the role of pain management
Regardless of what we may feel about the use of torture in the
treatment of prisoners, not treating the pain of prehospital patients,
putting them in the back of a truck, often on a hard piece of plastic,
and driving them over bumpy roads will often exceed the pain delivered
to those being intentionally tortured.
Why do so many of us not oppose torturing the people we are supposed
to be caring for?
Why do we allow people to work in EMS if they are comfortable with
this kind of treatment?
That applies to doctors, nurses, and medics.
> 2. Assessing pain scores
The numeric scale has many problems, but we need to be comfortable
with the patient describing pain in their own words. If only the
patient knows what their pain is, why do we feel the need to force
them to use our pain scale to describe something that they do not feel
is properly described by our pain scale?
If the patient says that he/she would like more pain medicine, is
there a good reason for us to say "No"?
> 3. Determining the most appropriate for the condition
I think that fentanyl is most often most appropriate, since it wears
off quickly.
The patient medicated to the point of being able to tolerate a bumpy
truck ride on a hard board on top of the rear axle may be overmedicated for laying on a thick mattress in the emergency department
with nurses assigned to several patients. In the ambulance, the medic
is closer to the patient than I am to my keyboard, right now. If the
medic cannot recognize side effects from that distance, then maybe the
medic should not be allowed to work as a medic.
The onset is less important than the rate at which it wears off.
If something is being treated, where the assessment may be affected by
the medication, having the medication wear off as the patient is
arriving in the emergency department should satisfy the fears of those
worried about narcosis.
Two relevant papers on this Appeal for fentanyl prehospital use.
Braude D, Richards M.
Prehosp Emerg Care. 2004 Oct-Dec;8(4):441-2. No abstract available.
PMID: 15626010 [PubMed - indexed for MEDLINE]
Safety and effectiveness of fentanyl administration for prehospital
pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed - indexed for MEDLINE]
> 4. Determining what the goal is for pain relief
The goal is a level of pain that is tolerable to the patient.
As long as the patient says that they want more pain relief, we should
not be deciding that 50 mg morphine, or whatever other dose, is too
much. If the patient is in pain, we should treat it.
There is nothing wrong with considering a different medication, if the
initial medication does not appear to be effective for that patient.
A short acting benzodiazepine (midazolam) is an excellent addition to
morphine/fentanyl. it wears off quickly, so any sedative issues should
be wearing off as the patient is arriving at the emergency department.
If it wears off sooner, more can be given.
Patients in pain often have accelerated metabolism, so they tend to
metabolize medication quickly.
Has anyone here ever needed to give naloxone to reverse the effects of
a therapeutic dose of morphine, or fentanyl, or dilaudid (other than
for procedural sedation)?
Anyone?
Ever?
> 5. Addressing the special needs of pediatrics
It is not any more ethical to torture children, cute little innocent
children, than it is to torture big mean adults.
> As for controversies? I would suggest we dis-spell the following
> 1. Pain management alters the physical exam
Fentanyl wears off quickly.
Naloxone can be titrated at 20 to 40 MICROgram doses if the patient
truly is experiencing narcosis.
> 2. Pain management removes a patient's ability to provide informed
> consent for additional treatment
Withholding pain management until a patient consents is coercion, as
Dr. Dailey is well aware. Dr. Dickinson wrote about that in this paper
Refusal of base station physicians to authorize narcotic analgesia.
Gabbay DS, Dickinson ET.
Prehosp Emerg Care. 2001 Jul-Sep;5(3):293-5. No abstract available.
PMID: 11446548 [PubMed - indexed for MEDLINE]
> 3. Is there a role for holistic measures such as bio-feedback,
> acupressure, aroma therapy, etc.
Only if they work better than placebo. If they are going to get a
placebo, having somebody hold their hand will be much more effective
than the acupressure/acupuncture placebo - even if their hand is being
held by a scary guy like me.
Tim Noonan
http://roguemedic.com/
Tim Noonan
> Hello!
> My name is Erik and I am new to the discussion group. I have been in the
> Pennsylania Emergency Medical Services for twenty-three years with the last
> seventeen years as a Nationally Registered Paramedic. I am very interested
> in learning about the constant changes that are occuring in pre-hospital
> medicine.
> I am happy that pain management has become a priority in the pre-hospital
> management of a patient even though it was way overdue. However, I think the
> biggest issue that faces pre-hospital providers are the "drug-seekers" and
> the concern of an Emergency Room physician/nurse saying "oh this guy is a
> drug-seeker how did you fall for that?"
I ask them to show me some well done research that shows how to
identify which patients are certain to be just junkies seeking drugs
for recreational purposes.
There is no such research. They are only fooling themselves, if they
claim to be 100% accurate. That is nothing but witchcraft/voodoo/
alternative medicine/BS.
Ask them - How many patients with genuine pain are you willing to
torture to prevent some junkies from getting high?
If they want to work for the Philly PD, they will take a huge cut in
pay, but they may be providing better patient care than they are as
the local Misery Cop/Nurse.
> Unfortunately, people who frequently abuse the system will create
> stereotypes and fear which results in hesitation on performing pain
> management. My question is how do we train our younger providers,
> physicians, and nurses to overcome this stereotype and at the same time
> recognize someone who is abusing the systems and is attempting to feed into
> an addiction?
Where in any EMS material does it mention education in identifying
people scamming the system to get some drugs?
That is not the job of EMS.
It is unfortunate that in West Philly this is a problem, but a short
acting drug, like fentanyl, is not going to be very satisfying for
someone looking to get well. It wears off too quickly.
Tim Noonan.
http://roguemedic.com/
> Dr. Isenberg's concern about patient's needing pain management and being
> triaged to BLS is a valid concern.
Erik Davis,
This is especially a concern in Philadelphia. Dr. Mechem (is he still
the medical director for the fire department?) has shown no interest
in pain management. When I would teach ACLS in city hospitals, the
medics would tell me that they were issued a maximum of 20 mg morphine
in a 5 pack of 4 mg syringes. They stated that they were not permitted
to restock anything until they were down to 4 mg morphine. If what I
have been told by a bunch of different medics is true, that is
horrible. what happens when they have a fire fighter - one of their
own - with serious burns?
What can be done to explain pain to these "grin and bear it" medical
directors?
I have run into similar problems with some of the medical directors in
the suburbs, but you hope for something better from someone working at
HUP.
> Personally, I think that it is a way of thinking that needs to be changed
> both with the BLS and ALS providers. . . .
We also need to get away from the idea that only chest pain, burns,
and isolated extremity fractures should be treated under standing
orders. Obviously, for those operating with even worse (none) standing
orders, we need to do something about the insanity of Mother-may-I
medical direction.
One of the other problems with short transport times is that some
medical command physicians will ask the completely irrelevant question
- How far are you from the hospital?
I answer that it depends on how quickly I get orders for pain
management - and I may have to call back several times if they are
stingy with the pain medicine.
I can always talk to the patient, for informed consent, and explain
that the doctor at the closest hospital does not want them to have
pain medicine. Would they like me to call somewhere else?
This "doctor shopping" is discouraged, but that is only because it
makes the bad doctors look bad. OK. Not really. The bad doctors always
look bad, but this just points it out to the bad doctors. They do not
like that. conversations usually do not progress amicably beyond this
point. however, once I point out to the doctor that I will consult
with the patient about the doctor's recommendation for pain management
orders, they usually give more appropriate orders.
When we get to the hospital, I also explain to the doctor that I am
protecting him/her from malpractice suits and charges of negligence,
which I would be happy to assist the patient with pursuing. I do not
receive a lot of thank you cards from the doctors for this, but I do
not really do this for the doctors. I do patient care for the
patients.
Tim Noonan.
http://roguemedic.com/
Laurie,
Quality of pain management in EMS ought to be studied, and I will bet the ranch that
a valid study would show that it's seldom done well.
But I would also like to see a study of pain management in the ER. I'm betting that it
would show significant deficits in pain management there also.
There seems to be some sort of culture in EMS and EM that pain management
should be limited because of perceived abuses by a few patients and some long-ago
dismantled notions that analgesia prevents the surgeon from adequately assessing
abdominal pain and so forth.
We forget that EMS does NOTHING without a physician's order, and when EMS pain
management is lacking, the fault is properly laid at the feet of the physician medical
directors.
There are many factors contributing to the reluctance of medical directors to
authorize appropriate pain management, one of which is the absolute stupidity of
the US Government's position, as promoted by the DEA, that all pain management is
somehow suspect, and that physicians who engage in pain management practice are
somehow encouraging drug abuse.
No wonder that EMS medical directors are reluctant to write standing orders for
adequate analgesia.
GG
Gene Gandy, JD, LP, NREMT-P
EMS Educator
Tucson, AZ
Gene,
I would take a slightly different take on this. I don't see the sub-culture saying it
should be limited because of a perceived abuse, but I see a sub-culture that has
developed over the last "few" years where patients have to somehow prove that
their problem is legit. I see many, many pre-hospital providers that emit a
perception that "they are faking it" or "they are a drug seeker" or (and my favorite)
"oh, they have anxiety, this can't possibly be an actual cardiac event" and these
perceptions can, if not properly addressed and corrected, lead to a lack of pain
management or an attitude of "they don't need anything" despite the complaint and
actions of the patient.
I do have another other question for the group. Have you seen or could you possibly
see an issue where the drive to protect the security of the controlled medications
leads to the development of processes that are so onerous that the medics do not
administer them except in the most extreme cases because they do not want the
hassle of wasting, replacing and documenting their use? With the increase in drug
diversion in the pre-hospital environment, (at least in Texas) how do we balance
security with ease of obtaining/administering?
Dudley Wait
Schertz EMS
Hi All,
My comments are mostly non-clinical in nature since I get to work with the
esteemed Dr. Kanowitz as our clinical guru.
I did have the opportunity to manage a medium size service in a large ski resort
community that literally used fentanyl by bucket. Our protocol for pain management
was a standing order for MS or fentanyl up to a limit, followed by a call-in if more
was required. Through an unintended quirk of fate and politics, our protocols
changed to "all standing order" concept and we really saw very little change in
prehospital pain management. Generally, fentanyl doses stayed under 200mcg
during scene calls without any reported troubles. MS remained our primary agent
for inter-facility use due to it's longer half-life. The one observation I do have is that
the all standing order situation was quite useful in actually increasing provider
accountability which we did not anticipate.
Considering our quantity of use, particularly in the winter months, control was a
major operational concern. For what is worth, our state allows for ambulance
services to be categorized a mid-level providers for DEA purposes and my opinion
was that our organization spent more time and effort on proper control procedures
because the medical director AND our department were both listed on the DEA
certificate.
Obviously our system was trauma heavy, so I can't recall any instances where our
providers we're suspicious of drug seeking behavior and we had pretty much
dispelled the surgeon's exam concern with the CT, MRI & ultrasound machines
many years before. We were always disappointed that nitrous oxide was
unavailable, but you have trouble getting a therapeutic concentration without
hypoxia at higher elevations. Cheers.
Sean M. Caffrey, CMO, MBA, NREMTP
System Development Coordinator
EMTS Section
Colorado Department
of Public Health & Environment
4300 Cherry Creek Drive South
Denver, Colorado 80246-1530
Office (303) 692-2916
Cell (720) 383-0250
Fax (303) 691-7720
Sean.Caff...@state.co.us
Hi to all
Entonox (nitrous 50%/oxygen 50%) was used in NSW, Australia for many
year prior to being replaced in the late 1990s by methoxyflurane.
Entonox was logistically difficult, having to cart around a large
cylinder. It was safe and effective, but little was written about it
from a research perspective. Methoxyflurane is commonly used in
Australia…administered through a lightweight inhaler held by the
patient, it is effectively self-administered at sub-anaesthetic
concentrations, generally with good effect, particularly in kids. One
of its downfalls is that it has to be constantly inhaled in order to
firstly achieve, then maintain analgesia. It also requires constant
instruction so ensure consistent breathing through the mouth and not
the nose! All clinical levels can administer methoxyflurane, with
many community first responders also being able to do so after
completing short courses.
Regards
Paul Simpson
Paramedic Research Fellow/Intensive Care Paramedic,
Ambulance Research Institute
Ambulance Service of New South Wales
And yet, Methoxyflurane has a slow onset/offset of effect, is a very
potent anesthetic (with a MAC listed as around 0.2%), a high degree of
lipid solubility, has to be consistently inhaled for proper effect, and
requires care by the medic to insure proper use.
sounds to me like it was a step backwards in safety to accommodate a
step forward in convenience for the ambulance operators.
ck
Charles S. Krin, DO (ret)
EMS writer and educator, former FP/EP
Hi to all,
I think Charles raises some interesting points. Certainly
methoxyflurane had its limitations as most analgesics do, but I would
suggest that it is not at all a step backwards as suggested. In
clinical practice, with constant inhalation, methoxy actually has a
very rapid onset of effect and upon ceasing inhalation has a quick
‘washout’. As presented in our recent publication in Prehospital
Emergency Care (Middleton et al 2010;14;439-447), provides effective
analgesia in almost 60% of adult patients with moderate to severe pain
to whom it is administered, with a mean reduction in patient reported
pain score of 3.2 points (VNRS). There are few safety issues with
methoxy in the sub-anaesthetic doses used for analgesia. Sedation is
rare. It has an excellent safety profile as an analgesic.
As previously mentioned though, it can be very frustrating getting
patients to comply with instruction. Entonox however was not a whole
lot different as a comparison. It had a slower onset, a faster loss
of effect, and still required patients to constantly inhale in order
to maintain the effect, and cart around a heavy cylinder. For
patients who have difficulty using the inhaler and maintaining
constant inhalation, the inhaler can be attached to a standard resus
mask (in much the same way Entonox was administered) providing a
better effect.
The use of methoxy in our service is declining as we recommend it for
mild pain only these days. We advocate opioid analgesia for moderate
and severe pain. All paramedics, except those still undertaking basic
induction training over their first three years, within our 2 tiered
ambulance service can provide opioid analgesia using either IV morph
or IN fent. So use of methoxy has really dropped off in recent times,
which is fine, as patients are getting the more effective opiate based
analgesia more often when they need it.
I agree that methoxy may not tick all the boxes as the ‘ideal’
prehospital analgesic, but it remains a very safe and reasonably
effective analgesic option that has a clear role amongst a multi-agent
approach to prehospital analgesia.
Have attached some refs for papers about methoxy to further stimulate
the discussion! As a first time participant in the forum, I am very
much enjoying the discussion!
Middleton PM. Simpson PM. Sinclair G. Dobbins TA. Math B. Bendall JC.
Effectiveness of morphine, fentanyl, and methoxyflurane in the
prehospital setting. <http://
ovidsp.tx.ovid.com.ezproxy1.library.usyd.edu.au/sp-3.2.2b/ovid...>
Prehospital Emergency Care. 14(4):439-47, 2010 Oct-Dec.
Babl FE, Jamison SR, Spicer M, Bernard S. Inhaled methoxyflurane as a
prehospital analgesic in children. Emergency Medicine Australasia
2006;18(4):404-10.
Buntine P, Thom O, Babl F, Bailey M, Bernard S. Prehospital analgesia
in adults using inhaled methoxyflurane. Emergency Medicine Australasia
2007;19(6):509-14.
Grindlay J. Babl FE. Review article: Efficacy and safety of
methoxyflurane analgesia in the emergency department and prehospital
setting. [Review] [57 refs] <http://
ovidsp.tx.ovid.com.ezproxy1.library.usyd.edu.au/sp-3.2.2b/ovid...>
Emergency Medicine Australasia. 21(1):4-11, 2009 Feb.
Regards
Paul Simpson
Paramedic Research Fellow/Intensive Care Paramedic,
Ambulance Research Institute
Ambulance Service of New South Wales
Hi
Nitrous oxide / oxygene 50/50 is a good and simple way for analgesia in
prehospital setting. Its efficiency was proven in many studies but never in this
situation and only for moderate pain. We do not know its efficiency for sever pain in
association with morphine, for example.
Question: Who know the prevalence of pain during the mobilisation of a trauma
patient in spite of analgesia? I mean that some spoke about fentanyl for the
mobilisation of patient but there is probably not a pain relief in all patients. So How
many patients are still painful in spite of analgesia with a narcotic, for example? Is
there reference about that?
Thank you
Michel Galinski
CNRD
Centre National de Ressources de lutte contre la Douleur
Hôpital Armand Trousseau
26, av Arnold Netter
75571 Paris Cédex 12
Tel :
+33 144735426
Secrétariat: +33 144735421
On Sep 22, 2:26 pm, galinski m <m.galin...@trs.aphp.fr> wrote:
> Nitrous oxide / oxygene 50/50 is a good and simple way for analgesia in
prehospital setting. Its efficiency was proven in many studies but never in this
situation and only for moderate pain. We do not know its efficiency for sever pain in
association with morphine, for example.
> Question: Who know the prevalence of pain during the mobilisation of a trauma
patient in spite of analgesia? I mean that some spoke about fentanyl for the
mobilisation of patient but there is probably not a pain relief in all patients. So How
many patients are still painful in spite of analgesia with a narcotic, for example? Is
there reference about that?
Dr. Galinski,
That is going to depend on a lot of things. Some people are more
responsive to opioids than others. The type of pain also matters. The
dose will have a significant effect. I remember reading that the range
of effective doses is very large. Comparing the effective dose at the
lowest end with the highest end, for opioid naive patients,k the high
end is ten times higher than the low end. this study does nothing to
contradict that. Unfortunately, I do not remember the source of that
range.
One study looked at a single 0.1 mg.kg dose of morphine. This study of
severe acute pain used a 50% decrease in the pain level as an
indication of adequate pain management.
Only 67% of patients had their pain decrease by at least half.
A 67% failure rate!
That is with a single 0.1mg/kg morphine dose. With the typical, at
least in America, ordered doses of 2 mg morphine, or even 5 mg
morphine, few patients are even approaching 0.1 mg/kg morphine. For an
80 kg patient (176 pounds), 2 mg is one quarter of this dose, that the
authors found to be inadequate. 5 mg is just a bit more than half of
the inadequate dose. Other studies have had similar results.
I discussed this study at length in a post on my blog.
http://roguemedic.com/2010/05/intravenous-morphine-at-0-1-mgkg-is-not...
Intravenous morphine at 0.1 mg/kg is not effective for controlling
severe acute pain in the majority of patients.
Bijur PE, Kenny MK, Gallagher EJ.
Ann Emerg Med. 2005 Oct;46(4):362-7.
PMID: 16187470 [PubMed - indexed for MEDLINE]
I sent a copy of the study to Mic to post.
The podcast of Dr. Edward Gentile talking about the very aggressive
morphine protocol used in his hospital without problems is at http://blog.emcrit.org/podcasts/gentile-pain/
The follow-up post explaining the routine use of diphenhydramine is at
http://blog.emcrit.org/blogpost/comments-on-pain-protocol/
Titration is the only appropriate way to manage pain. Either side
effects prevent titration from continuing to the point of adequate
relief of pain, or the patient experiences adequate relief of pain.
Titration should not have any maximum dose. What would be the point?
With 0.1 mg/kg as a starting dose, rather than a total dose, the
pathetic 67% failure rate would be much, much lower.
Tim Noonan.
http://roguemedic.com/
Tim,
Thanks for sending me the PDF of that article and several others. I
have most of them now indexed and upload onto the resource page for
this topic (http://groups.google.com/group/naemsp-dialog/web/topic-4--prehospital-pain-management). Here is what's available for download as
PDFs so far:
- Alonso-Serra H, Wesley K: NAEMSP Position Paper - Prehospital Pain
Management. Prehosp Emerg Care 2003; 7:482-488.
- Bijur PE, Kenny MK. Gallagher EJ: Intravenous Morphine at 0.1 mg/kg
Is Not Effective for Controlling Severe Acute Pain In the Majority of
Patients. Ann Emerg Med 2005; 46:362-367.
- Braude D, Richards M: Appeal for Fentanyl Prehospital Use (Letter to
the Editor). Prehosp Emerg Care 2004; 8:441-442.
- Galinski M, et al: Out-of-hospital emergency medicine in pediatric
patients: prevalence and management of pain. 2010 Am J Emerg Med
(article in press).
- Galinski M, Ruscev M, Gonzalez G, et al: Prevalence and Management
of Acute Pain in Prehos[pital Emergency Medicine. Prehosp Emerg Care
2010;14:334–339.
- Kanowitz A, Dunn TM, Kanowitz EM, et al: Safety and Effectiveness of
Fentanyl Administration for Prehospital Pain Management. Prehosp Emerg
Med 2006; 1-7.
- Middleton PM, Simpson PM, Sinclair G, Dobbins TA, Bendall JC:
Effectiveness of Morphone, Fentanyl, and Methoxyflurance in the
Prehospital Setting. Prehosp Emerg Med 2010;14:439–447.
- Rupp T, Delaney KA: Inadequate Analgesia in Emergency Medicine. Ann
Emerg Med 2004;43:494-503.
- Shavit I, Hirshman E: Management of Children Undergoing Painful
Procedures in the Emergency Department by Non-Anesthesiologists.
Israel Med Assn J 2004; 6:350-355.
- Svenson JE, Abernathy MK: Ketamine for prehospital use: new look at
an old drug. Am J Emerg Med (2007) 25, 977–980.
- Veysman BD: Truth Hurts. Acad Emerg Med 2009.
If anyone has other articles that would be useful to add to this
collection for the reference of those interested in reading more about
this topic, please send them to me at mic.gunder...@gmail.com.
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
On Sep 20, 6:56 pm, "Koehler, Danita N Dr CIV USA MEDCOM MEDDAC-AK"
<danita.koeh...@us.army.mil> wrote:
> TWO articles are worth review:
> 1. CDC MMWR report (59:32 1026) "The number of poisoning deaths from
> opiates (1997=4000 deaths 2007=14,500 deaths)"
> 2. CDC MMWR report (59 (30);957 Death Rates for the three leading
> causes of Injury Death" in which deaths from MVA and firearms has
> dropped but death from drugs is on exponential rise.
Here is a link for the first report http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5932a6.htm?s_cid=mm5932
a6_w
There is no suggestion that EMS administration of opioids contributed
to even one of these deaths.
Here is a link for the second report http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5930a6.htm?s_cid=mm5930
a6_w
Again, there is not even a suggestion that EMS administration of
opioids contributed to a single opioid death.
Do you have any data on any death of any patient due to the
administration of opioids by EMS? Or are you just pointing out that the abuse of
opioids has increased among the general public?
Tim Noonan.
http://roguemedic.com/
Query: Can methox be used in conjunction with opioid analgesics? For
example, let's say that the methox doesn't quite do the job. Can you
add in some fentanyl? Any problems with that? Could you use lower
doses of fentanyl if you paired it with methox?
Gene
(Gene Gandy, Tucson, AZ)
Hi Jason Bendall here from the Ambulance Research Institute in Sydney.
In our recent publication (Prehospital Emergency Care 2010;14;439-447)
there was no compelling evidence that combinations were more effective
than morphine alone. Our service has used methoxy, morphine and IN
fentanyl alone or in combination for some time. Based on our results
we encourage our paramedics to use morphine as first line for
moderate / severe pain as it appears the most effective option. That
being said, methoxy is an effective agent in its own right. In answer
to your question though, there is no issue with giving methoxy and if
inadequate giving an opioid. I am of the view however that if
possible, give morphine initially as it is associated with much higher
odds of effective analgesia.
Dr Jason Bendall
MBBS MM(ClinEpi) PhD FACAP
Jason:
In your study, did you notice a problem with histamine release or
other forms of morphine intolerance?
ck
Charles S. Krin, DO, retired FP, ED and EMS physician
Hi Charles, to be honest we only looked at records from a database so did not look at
this issue specifically case by case (almost 13,000 patients given morphine). Our
Jurisdiction has however used morphine for over 30 years and are unaware of any
significant issues. Our jurisdiction gives thousands of patients morphine annually.
Over my 15 years with ASNSW it has not cropped up that often. In saying that I have
had some patients with localised erythema post administration of morphine.
Regards
Dr Jason Bendall
Jason:
Thank you. I'm quite surprised, and it may be due to some genetic
variation. Anecdotally, I saw significant histamine symptoms in almost 15% of the
patients that I treated during my career. A small percentage, like my ex
wife, had a severe, anaphylactoid type reaction. including swelling of the
face and tongue, generalized wheal and flare, and occasionally wheezing.
Then again, in that same patient population (Louisiana, 1988-2005), it was
not unusual to have significant problems with sphincter of Oddi 'squeeze'
due to morphine, resulting in an increase in gall bladder symptoms.
ck
Charles S. Krin, DO
Retired FP/EP/EMS physician, educator and author.
May I add in this: In patients with renal insufficiency or chronic renal failure Stage
II or III, morphine carries some cautions. While at one time it was thought that
morphine levels accumulated in patients with renal insufficiency, now it has been
shown that it's metabolite, Morphine-6-glucuronide (M6G), if I understand it
correctly, is the agent that accumulates in renal-impaired patients. That metabolite,
if I understand correctly, has significant mu receptor blocking powers and can also
depress respiratory depression. Therefore, I am told that MS should be
administered with caution to patients in renal failure, OR, the doses should be
reduced significantly. There seem to be a plethora of studies out there, all of which
will pop up with a Google for "morphine metabolites."
Not being a pharmacist nor a chemist, I run the risk of misunderstanding what I'm
reading sometimes, but my reading seems to tell me that fentenyl or alfentanyl are
the analgesics of choice for patients with renal insufficiency.
Fentanyl seems to have neither the histamine release problems nor the metabolite
build-up problems of morphine.
Can anyone comment on this? Is there any significant risk in choosing one over the
other in prehospital care given generally short scene to hospital transport times?
GG
Gene Gandy, JD, LP, NREMT-P
EMS Educator
Tucson, AZ
Dr. K,
Would fentanyl produce the same problems with the S of O?
GG
Gene Gandy, JD, LP, NREMT-P
EMS Educator
Tucson, AZ
Gene: to the best of my (off the cuff) knowledge, that problem is specific
to morphine, and is probably related to the known problems with histamine
release and morphine.
ck
Charles S. Krin, DO
Retired FP/EP/EMS physician, educator and author
All,
I think the best answer is weight based or reasonably developed protocols of
titrated doses of narcotics will rarely lead to complications. Can they--sure. M6G is
an active metabolite, and as such will be causing the effects you are seeking;
therefore titrated doses of morphine will be fine. Demerol is another story, where
normeperidine is a metabolite that does not have analgesic properrties and will
cause seizures at high levels.
I think we are rapidly arriving at two main threads here. First, how do we get people
to use medications for patients with pain? And second, what are the optimal agents
and treatment regimens. I wish I had an answer to the first, and hope to learn from
others. For the second, I believe we need a medication that can be titrated rapidly to
reasonable analgesic effect, and fentanyl, 1 mcg/kg, followed by 0.5 mcg/kg
repeated in 5 minute intervals seems to be the best narcotic option.
Michael
ps: One other thought: in accordance with recommendations for safe documentation
practices, can we please refer to morphine as "morphine" and not MS? It's an old
trap we all fall into from time to time.
Michael W. Dailey, MD FACEP
Director of Prehospital Care and Education
Associate Professor of Emergency Medicine
Albany Medical Center
518/ 262-3773
Here in the US I suggest that we in prehospital care now tend to find
that fentanyl is better at achieving effective analgesia in the short
run than morphine, and so many EMS services now carry both morphine
and fentanyl. Fentanyl is used for skeletal injury pain and visceral
pain, and MS for cardiac pain, CHF, and so forth, although there are
discussions going on about whether or not morphine has any real
advantages other than length of effect. I like fentanyl because I can
give it to a hip fracture patient a couple of minutes after I arrive,
and in 5 minutes, she'll be pain free enough for me to be able to move
her without subjecting her to excruciating pain. MS would take three
times as long.
So I'm wondering what the thinking is in Australia about morphine vs.
fentanyl?
Also, here, some services are now carrying hydromorphone (Dilaudid).
Any thoughts about that?
It's of great interest to me how we come to different conclusions
about choice of drugs depending where in the world we are.
A appreciate your response and your thoughts.
Gene Gandy
We should also mention that fentanyl can be given intransasally, which
is great for the pediatric population. A quick spray can relieve pain
without the discomfort of an IV.
A randomized controlled trial of intranasal fentanyl vs intravenous
morphine for analgesia in the prehospital setting *
*
*
*The American Journal of Emergency
Medicine*<http://www.sciencedirect.com/science/journal/07356757>
*Volume 25, Issue
8*<http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=
%23TOC%236685%232007%23999749991%23670221%23FLA
%23&_cdi=6685&_pubType=J&view=c&_auth=y&_acct=C000050221&_version=1&_
urlVer sion=0&_userid=10&md5=22a1a7059b6b0bb48861c37a553fec90>
*, October 2007, Pages 911-917*
A randomized controlled trial comparing intranasal fentanyl to
intravenous
morphine for managing acute pain in children in the emergency
department.
Borland M<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Borland%20M
%22%5BAuthor%5D>,
Jacobs I<http://www.ncbi.nlm.nih.gov/pubmed?term=%22Jacobs%20I
%22%5BAuthor%5D>,
King B
<http://www.ncbi.nlm.nih.gov/pubmed?term=%22King%20B%22%5BAuthor
%5D>,
O'Brien D<http://www.ncbi.nlm.nih.gov/pubmed?term=%22O'Brien%20D
%22%5BAuthor%5D>.
Ann Emerg Med. 2007 Mar;49(3):335-40. Epub 2006 Oct 25.
Derek Isenberg, MD, NREMT-P
Medical Director
Mercy EMS
Mercy Catholic Medical Center
Department of Emergency Medicine
501 South 54th Street
Philadelphia, PA 19143
215.748.9740
215.748.9208 (fax))
Hi
About Fentanyl,
We can not say that fentanyl is better than morphine. There is not study to
confirm that.
There is currently 2 published studies in prehospital setting (fenta vs
morphine (2005) ; sufenta vs morphine (2010)). The last one (in press)
compared morphine and sufentanil (titrated, IV) in trauma patients in
prehospital setting. This study showed that the rate of relief patient was
better only one time, at 9 minutes after injection in sufentanil group. But
3, 6, 12 and 15 minutes there was no difference. However morphine was better
in the next hours (6 hours follow up). Bounes et al Ann Emerg Med 2010 (in
press).
Kind regards
Michel Galinski
Centre National de Ressources de lutte contre la Douleur - CNRD.
H pital Armand Trousseau
26, av Arnold Netter
75571 Paris cedex 12
Secretariat: 01 44 73 54 21
Site internet: www.cnrd.fr
Hi Paul, yes this is a subject that interests me - from a clinical
reasoning aspect and also from a attitudinal perspective. There is
limited research into paramedic attittudes towards analgesia - Jones &
Machen 2003; Hennes, Kim & Pirrallo 2005 are a couple that spring to
mind that explored this somewhat. I think that there is a lack of
education about pain theory - physiology, patient-focused assessment
of pain, and appropriate pain management. It is unfortunate that many
services have limited pain management options, further 'boxing'
paramedics thinking towards the management of pain.
I'm looking foward to reading the rest of this discussion!
Sarah Werner
Sarah Werner
CEU Tutor, Advanced Paramedic
St John, New Zealand
In New Zealand, we have used 50% nitrous oxide / 50% oxygen (Entonox)
for many years with good effect. In 2007 we introduced methoxyflurane,
but in some areas the economics of using methoxyflurane has meant that
Entonox has replaced methoxyflurane... Our procedures (which have a
good amount of latitude in them) indicate Entonox for mild-moderate
pain. Entonox is safe to use, the cylinder can be last more than one
patient, and patients acheive good short term relief - if properly
instructed in the use, have an adequate tidal volume for inhalation,
and the patient has the ability to comprehend and self-administer.
Methoxyflurane is indicated in our procedures for moderate to severe
pain. Both can be administered at BLS level, hopefully meaning that
our patients get short-term analgesia, with the option of ILS / ALS
backup for parenteral analgesia (we have morphine, ketamine and
midazolam available for use).
Sarah Werner
CEU Tutor, Advanced Paramedic
St John, New Zealand
The discussion has gotten quiet and we have had the topic open for
over a month now, so I'm going to ask if any of our invited
participants or others have any closing remarks or summations , to
please post them today or tomorrow.
Thanks,
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
Pain. We've talked about it a lot, discussed "evidence" and clinical practice.What we
have all said it that EMS providers should have options for treating pain. Some
alternatives won't be medications, and while some of the medications will be
injectable, some should be either oral, inhaled or intranasal. Some of the
medications options studied in other parts of the world will not be options in the US.
Providers must focus on the pain as their patients report it, but this may not always
mean administering medication.
So what are my last thoughts as we close the thread?
For physician medical directors: Give your providers the tools and training to do the
job. Advanced providers should have access to opiate analgesia for their patients.
Fentanyl offers the option of intranasal as well as IV or IM administration. Consider
working with your regulators to allow standing order administration of narcotics
within specific practice parameters--physician online medical command does not
decrease the opportunity for diversion, it merely delays care for patients. Good
medical oversight, CQI and narcotics record keeping reduce the chance for
diversion.
For managers: Have strict but reasonable narcotic oversight. Administrative
requirements should not prevent care. Study diversions that have occurred
elsewhere and use them as lessons. Make sure there are programs available for
providers in crisis, before they dip into the narcotics.
For providers: Focus on pain, evaluate your patients for pain, treat appropriately
and document accordingly, and most of all, treat your patients as you would want to
be treated.
Be safe.
MD
Michael W. Dailey, MD FACEP
Director of Prehospital Care and Education
Associate Professor of Emergency Medicine
Albany Medical Center
518/ 262-3773
and for all: remember that sometimes the best anodyne for pain is a smooth
ride, a gentle smile, and a warm hand to hold.
ck
Charles S. Krin, DO
Retired FP/EP/EMS physician; educator and author
Requirements for on line medical command permission only deprive the
patient of appropriate care.
There is nothing about being a doctor on the other end of a radio or
phone call that improves the safety of the use of opioids to treat
pain.
As Dr. Daily wrote: "Give your providers the tools and training to do the job."
If medical directors lack confidence in the abilities of their
paramedics, then the answer is to better educate those paramedics.
This is not really difficult. Possible means of education include
observing/participating in procedural sedation in the emergency
department. This would not be a preparation for paramedics performing
procedural sedation, but for educating paramedics about the assessment
of respiratory depression.
If there is a burn center near by, have paramedics rotate through the
burn center to get some experience with the treatment of severe pain
with large doses of opioids. Again, not to prepare them to use such
large doses (unless they have patients with similar burns), but to
learn to assess the patient's response to pain medicine and to assess
for respiratory depression.
Encourage the use of waveform capnography.
Waveform capnography is the best safety net in all of EMS.
Even if you never give a patient anything stronger than an aspirin,
competence with waveform capnography is essential for competence in
EMS.
Is there any good reason a patient in pain should have to wait until
arriving at the emergency department to receive adequate pain
management.
There is no maximum dose of any opioid (except for meperidine/
pethidine, but that is the wrong drug to use), the maximum dose is
whatever the patient says produces relief or whatever produces
unacceptable side effects before relief of pain.
100 mg morphine is not too much - what matters is the response of the
patient.
1,000 mcg fentanyl is not too much - what matters is the response of
the patient.
Should any medical director authorize any paramedic to treat patients
with opioids without determining if the paramedic can titrate opioids
to pain relief or to side effects?
Tim Noonan.
http://roguemedic.com/
Dear all
Unfortunately I have had limited contributions to this debate, however I can only
agree with the last contributor. In truth there are some potential benefits to direct
online medical involvement in EMS, but analgesia is not one of them. In Australia we
manage entirely without this oversight (over 3000 paramedics in our Service, over 1
million calls each year and a state the size of Texas), and appear to manage acute
prehospital pain both safely and appropriately, as described in our recent PEC
paper.
No patient should wait for adequate analgesia, and the responsibility of a medical
director is to enable clinicians in the prehospital segment of the emergency care
continuum to give appropriate and adequate interventions which are comparable to
those in the in-hospital segment. These are the same patients, with the same
problems, and this needs to be recognised. The further responsibility of the MD is to
put in place training which enable prehospital clinicians to recognise, mitigate and
manage the side-effects of the appropriate treatment, in exactly the same way as the
in-hospital guys.
If there is any doubt about what the appropriate intervention is in these
circumstances, just ask the patient ehat they think. Same patient, same problem,
different place.
Paul
Paul M Middleton
Director, Ambulance Research Institute
Medical Director, Ambulance Service of NSW
Not sure if this had been posted yet as part of the discussion, but here is link to
NAEMSP position statement:
http://www.naemsp.org/pdf/Prehospital_Pain_Management.pdf
Brendan Kearney, MPA, EMT-P
Superintendent in Chief
Boston Emergency Medical Services
767 Albany Street * Boston * MA 02118
Phone: (617) 343-2367 * Fax: (617) 343-1199
Email: Kear...@bostonems.org * Website: http://www.cityofboston.gov/ems/
I completely agree with Gene and Michael. We must come together as a
professional body and approach the states with restrictive protocols
in an attempt to give them advice and encourage them to examine this
extremely important issue.
One way for providers and services to justify these changes is to
actively assess all patients for pain and provide medical directors
and state officials with real data of the need. This issue can not be
addressed with anecdotal accounts.
I'm optimistic that together we can do this.
Keith Wesley, MD
Medical Director
HealthEast Medical Transportation
St. Paul, MN
- The lack of appropriate pain management is the problem.
I don't believe the solution is a single medication or protocol. I
believe the start to a solution is an understanding as to why we are
so poor at pain management.
For the provider:
- De-emphasize the need to identify who is really in pain and who is
just seeking pain medications.
- Treat all pain, whether it be BLS or ALS treatment.
- Gauge the pain off of the subjective information provided by the
patient (i.e. severity scale)
For the services:
- Train your people that a narcotic dependency is not a prehospital
contraindication for pain management.
- QA these 'pain calls' as if it were an AMI patient who hadn't
received aspirin.
- Provide as many pain management options as possible with appropriate
education and protocols regarding each one.
For all of EMS:
- Keep the discussion going!
- Follow the evidence.
That is just my take on the topic. I am always subject to alter my
opinion as a result of being proven wrong...
Adam Thompson, EMT-P
Lee County EMS
EMS Educator - Edison State College
Paramedicine101.com
EMSworld.com
Lee County, Florida
I would like to agree with Adam's spot on list and add one more. Remove
barriers to the giving of analgesic medications. Requiring that certain
medications be in a safe in the truck instead of routinely carried to the
patients side with the rest of the drug box, has been demonstrated to reduce
usage. The need to chase down a particular attending for a signature when
drugs are given and then replace meds by catching the pharmacist at a
certain time by going down two flights of stairs through a tunnel and over a
bridge to find the pharmacy are all barriers to appropriate use of
analgesics.
David Tauber, NREMT-P, CCEMT-P, FP-C, NCEE, I/C
Education Coordinator
77-D Willow Street
New Haven, CT 06511
(203)562-3320 ext. 202
(203)562-9070 fax
www.sponsorhospital.org
dtau...@sponsorhospital.org
Just before this session on pain management comes to a close, I'd like
to ask that if anyone has articles, other documents or links that they
think might be helpful to others seeking information on the topic, to
please send those items to me directly at mic.gunder...@gmail.com.
They will be considered for use on the pain management resource page
that will be also contain a condensed version of the pain management
discussion thread. The intent is to have each of these resource pages
become a place where those looking for information to use in updating
their protocols, policies and procedures can tap into the collective
wisdom and resources of the list members and invited participants.
Several changes are underway because the structure of Google Groups is
changing. The discussion threads will remain here but the file storage
and page capabilities will be removed. As a result, the Dialog
resource pages with the condensed discussion threads and associated
document files and links will be relocated to a new Google Site page.
As these changes are implemented, I will update you.
Thanks ever so much to all of our invited participants - Jason
Bendall, Bryan Bledsoe, Michael Dailey, Michel Galnski, Paul
Middleton, Paul Simpson and Keith Wesley.
Finally, thanks to all of you for your participation and letting your colleagues know
about this resource. We are now up to 257 members. Please continue to let people
know about it. The more EMS professionals we have here, the more
collective experience and wisdom we will be able to tap into and the
wider the information will be disseminated.
Thanks,
--- Mic
Mic Gunderson
Editor/Moderator
NAEMSP Dialog;
President, IPS