Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Oh What a Relief It Is! Pain Management in EMS Laurie A. Romig, MD, FACEP Medical Director Pinellas County (FL ) EMS ‘‘We must all die. But that I can save a person from days of torture, that is what I feel is my great and ever-new privilege. Pain is a more terrible lord of mankind than even death itself.’’ -Albert Schweitzer Objectives Provide a better understanding of how badly we and the rest of the medical profession handle pain Identify some of the barriers to better pain management for all patients Describe some common pharmacological pain interventions Describe some nonpharmacological pain interventions Survey says: Do you believe that prehospital pain management is a: High priority and important goal Nice to do if you have the time, but not a priority Not at all important Not our job or our problem (nobody ever died of pain) Survey says: How many of you have: Protocols for pain meds before or without medical control contact Protocols for pain meds only after medical control contact IV opiates Intranasal opiates Other non-opiate analgesics such as ketorolac (Toradol) BLS measures only Survey says: How well do you think your service does with pain management? We do great. Nobody suffers unnecessarily Pretty good, but we could do better Not very well What pain management? Prevalence of Pain Studies show that pain of some type is a presenting complaint for up to 70% of all ED patients The percentage for EMS is probably similar. One study showed that 20% of EMS patients complain of at least moderate to severe pain Other studies show that all medical practitioners, including EMS are poor pain evaluators and managers JCAHO now recognizes pain evaluation as the “fifth vital sign” and judges hospitals on their pain management policies In many cases, pain relief is the primary expectation of our patients In many cases, it is the ONLY thing that we can offer the patient other than transport to the hospital Pain management is often neglected or, at best, delayed in Emergency Departments EMS Literature 1073 patients with suspected extremity fractures only 1.8% were administered analgesics 17% received ice packs 25% received air splints Akron Fire Department Published 2004 EMS Literature 124 patients with ED diagnosis of hip or lower extremity fractures 18.3% were administered field analgesics 91% received analgesia in the ED (ED patients - 2 Hour Delay) William Beaumont Hospital, Royal Oak, Michigan Published 2002 EMS Literature 128 elderly patients with field diagnosis femoral neck fractures 51% received field pain management Only 2 patients received splints in the field Westmead Hospital, Sydney, Australia Published 2003 Why is oligoanalgesia so prevalent? Few EMS textbooks devote significant attention to pain management EMS education on pain management lacking Many EMS systems do not have pain management protocols Why is oligoanalgesia so prevalent? EMS personnel want to avoid conflict with ED physicians ED physicians want to avoid conflict with surgical consultants Myths About Pain Management Care providers can accurately assess a patient’s pain by observation Pain affects all people in the same way Everyone responds to analgesics in the same way Analgesia can create difficulty in assessing abdominal pain and other clinical conditions Myths About Pain Management Patients become unable to give informed consent Use of narcotics in acute pain leads to increase in addiction Analgesic use in the field is unsafe Myth: Care providers can accurately assess pain by observation Self-reporting is actually shown to be the most accurate reflection of pain intensity, NOT the care provider’s opinion Care providers are influenced in their subjective evaluations by other patient factors and by their prior personal and professional experience with pain Myth: Pain affects all people in the same way Pain perception is affected by: Age (KIDS DO HURT AND THEY DO REMEMBER IT!) Gender Race Culture Emotions Cognitive state Previous experience Pain Assessment Objective measures of pain ratings improve pain management Help to balance imprecise clinician pain assessment Assist in tracking success of pain management Are available for both adult and pediatric ages, even down to neonates! Pain Assessment Numeric Rating Scale 0-10 0 = No pain 10 = The worst pain you can imagine Requires verbal and cognitive ability Pain Assessment Visual Analog Scale 10 cm line with left end being “no pain” and right end being “worst pain imaginable” Have patient mark their pain level on the line Pain level measured in millimeters Requires vision, cognition and relatively large amount of space to perform Pain Assessment Verbal Rating Scale None, mild, moderate, severe, unbearable Requires cognitive ability Pain Assessment Wong-Baker FACES Scale Works well for pediatrics Also works well for some adult patients unable to perform other scales Also comes in a 0 to 10 format Myth: Everyone responds to analgesics the same way Many factors can affect how a given drug and dose will affect different people Body weight Lean vs. total Hemodynamic status Drug tolerance Metabolic rate Concurrent drug use Myth: Analgesics can create difficulty in physical examination and diagnosis A number of studies have shown that early administration of analgesics Allows patients to relax Removes voluntary guarding Permits better assessment of localized tenderness Myth: Analgesics can create difficulty in physical examination and diagnosis Administration of morphine to pediatric patients with abdominal pain did not affect the clinician’s ability to recognize children with surgical conditions Published 2002 Myth: Analgesics can create difficulty in physical examination and diagnosis In a survey of emergency medicine physicians ED physicians believe judicious use of pain medication does not compromise physical exam BUT the majority withheld analgesics until after evaluation by the general surgeon Published 2000 Myth: Patients become incapable of giving informed consent Multiple studies show that patients retain their ability to give informed consent despite the effects of analgesics Myth: Use of narcotics in acute pain leads to an increase in addiction NO research supports this Assumption is often based on the fact that many people appear to become “drug-seekers” after an acute injury In fact, these “drug-seekers” are often only the victims of inadequate pain management (oligoanalgesia) and a medical culture that does not recognize it’s own limited understanding of pain issues A note about “drug-seekers” Check with your medical director about his or her philosophy In general, EMS should NOT be attempting to determine if a patient is a drug-seeker Especially without an on-going familiarity with the patient Doing so may cause you to unfairly undertreat patients Myth: Analgesics are Unsafe One study evaluated 84 cases using small doses (2-4 mg) of morphine Only one case of MS induced respiratory depression was found Published 1992 Myth: Analgesics are Unsafe Another study reviewed 131 air-transported patients who received fentanyl. There were no untoward events Published 1998 Myth: Analgesics are Unsafe 2129 patients administered fentanyl in the field 12 patients (0.6%) had a VS abnormality due to fentanyl administration Only 1 patient required a recovery intervention Published 2005 Remember that any analgesic (and most EMS drugs) CAN be unsafe in the field if used outside of reasonable protocols and standard of care boundaries and without appropriate quality management. Let’s take a break! Safe Use of Analgesics Understand the concepts of time of onset of action and peak effect (pharmacodynamics) and the values for each drug you use Giving additional doses of medication prior to a previous dose taking effect puts you at risk for creating a problem for the patient Safe Use of Analgesics Slow and steady is better than hard and fast Titrate small doses at appropriate intervals Safe Use of Analgesics Beware the effects of combining drugs Particularly when added to not taking pharmacodynamics into account, adding one CNS depressant or hemodynamic depressant drug to another can create unpredictable changes Safe Use of Analgesics Don’t forget to ask about medication allergies, current medications and when they were last taken Remember to look for Fentanyl patches!! Adding IV opiates on top of recently taken oral sedatives, analgesics or muscle relaxants may cause unpredictable additive effects as well Safe Use of Analgesics Know your pain management goal Does your pain management protocol have a goal? ”Make the ride more bearable”? “Decrease pain by 50%”? “Decrease pain to “x” or less”? “Make patient painfree”? Your goal may actually be different for different types of patients Safe Use of Analgesics Reassess the patient (including pain scale) frequently Document carefully (including pain scale) Take the patient’s hemodynamic state into account if your medication may affect it Safe Use of Analgesics Always give complete report to ED staff regarding drugs given, time given, and results or adverse reactions It can be difficult to sort out whether changes in level of consciousness or development of respiratory or circulatory compromise are due to the drug or to underlying illness or injury without good info on timing and sequence Who should receive analgesics? As always, go by your own protocol Your local protocol may depend upon your medical director’s attitudes and experience with pain management and/or your medical community’s Who should receive analgesics? Your protocol may (and should) address Abdominal pain patients Pediatric/infant patients Headache patients Trauma patients (particularly multiple blunt trauma) Hemodynamically unstable patients The elderly Short transport time patients Who should receive analgesics? Your protocol MAY contain minimum pain level requirements or specifications for acute versus chronic pain ED docs may complain about what they perceive of as “minor” patients receiving IV analgesics They may also complain about chronic or subacute pain patients receiving IV analgesics Who should receive analgesics? Remember that nonpharmacological pain management methods are usually safe and can be surprisingly effective Ice or heat Elevation Splinting/positioning Emotional support Distraction (guided imagery, biofeedback, breathing exercises) Common Prehospital Analgesics How do I choose? Desirable characteristics for EMS analgesic Quick acting (short onset and peak effect) Short duration Minimize side effects Hypotension, respiratory suppression, emesis, etc. Easy to administer Multiple administration routes available Reversible Inexpensive How do I choose? Take patient allergies into consideration Take patient condition into consideration Use the least hemodynamically active agent if patient is unstable Sometimes it’s a crap shoot! Individual patients may react better to some drugs than to others, but usually it’s still just a matter of giving ENOUGH drug My Favorite… Fentanyl Fentanyl (Sublimaze) An opiate with sedative and analgesic properties Used in OR’s for many years, has become much more common in ED’s and EMS in last 5 years or so May be used IV, IM, intranasal, transmucosal, and transdermal May be used safely for both adults and children Fentanyl May be used for pain management (including cardiac ischemia), sedation, and as part of facilitated intubation and/or rapid sequence intubation Reversible with Narcan Causes less emesis than Morphine Inexpensive No cross-reactivity in morphine allergic patients 100 x as potent as morphine Fentanyl Generally minimal effect on blood pressure, heart rate and ventilatory drive Helps to blunt HR and BP associated with intubation Chest wall rigidity or muscle twitching can occur Should be reversible with Narcan Most side effects result from pushing the medication too quickly Fentanyl Onset of action IV: 1-2 minutes IM and IN: 7-15 minutes Peak effect IV: several minutes IM and IN: 15 minutes Duration of effect IV: 30-60 minutes IM (and IN?): 60-120 minutes Fentanyl Dosing for pain management 1-2 mcg/kg IV over at least one minute q 1-3 minutes for hemodynamically stable peds and non-elderly adults Some services deliver in 50 mcg increments rather than by weight Recommend starting with 0.5 mcg/kg for elderly and hemodynamically unstable patients Note: For all opiates, reduce doses if using another CNS depressant concurrently. Fentanyl Dosing for pain management IM dose: Few recommendations in literature. Would start with IV dose but remember that it will take MUCH longer to have initial and peak effect IN dose: Depends on concentration you have available. Dr. Tim Wolfe recommends 1.5 mcg/kg per dose, but can only administer max of 1 cc of fluid per nostril Fentanyl Dosing for sedation Light, anxiolytic sedation: 1 mcg/kg IV Deep sedation for procedures: 2-3 mcg/kg IV (fentanyl alone) or 1-2 mcg/kg IV (fentanyl with another agent) Once you get above 3-4 mcg/kg you’re looking at general anesthesia level doses! Morphine An opiate with sedative and analgesic properties Still considered by many to be “The Gold Standard” May be used IV, IM, SC or orally May be used safely for adults and pediatrics Morphine Reversible with Narcan More likely to cause emesis than Fentanyl Inexpensive Opioid potency is compared to 10 mg of morphine IV 10 mg morphine IV equivalent to 100 mcg (0.1 mg) of fentanyl IV Morphine More likely to cause respiratory depression, hypotension, bronchospasm and tachycardia than fentanyl due to histamine release May actually increase intracranial pressure Morphine Onset of action IV: 5-20 minutes (longer than fentanyl) IM: ? Peak effect IV: 30 minutes (longer than fentanyl) IM: ? Duration of action IV: 2-3 hours (longer than fentanyl) IM: 3-5 hours Morphine Dosing for pain management 0.05-0.3 mg/kg IV Many protocols call for increments of 2-4 mg IV titrated for adults, others for doses of 5-10 mg IV May be wise to do a “test dose” of 1-2 mg to gauge hemodynamic effect Typical pediatric dose is 0.1 mg/kg IV Typical IM dose for adult is 5-10 mg Nitrous Oxide Inhalation agent with analgesic and anesthetic properties In use for many years Usually 50/50% mix with oxygen Onset and duration of action: 3-5 minutes Can be self-administered Nitrous Oxide Do not secure mask to the patient’s face Mask will fall away if patient becomes oversedated Effects rapidly wear off Side effects mostly nausea/vomiting Contraindicated for suspected pneumothorax, possible bowel obstruction and other situations where gas may be entrapped in a closed space of the body Nitrous Oxide Discontinued in some EMS systems because of abuse problems Potential for gas to enter the ambient atmosphere and affect EMS providers Butorphanol (Stadol) Opiate agonist-antagonist Because of this, Stadol is thought to create less respiratory depression and less risk of drug dependence with chronic use May be used IV, IM or IN Can cause withdrawal symptoms if used in patients who are narcotic dependent May also cause need for increased doses of other narcotics for subsequent pain management and/or anesthesia Butorphanol (Stadol) Relatively unpredictable effectiveness Nalbuphine (Nubain) is similar drug Both are considered less than ideal prehospital drugs Butorphanol (Stadol) Onset of action IV: 1 minute IM/IN: 15 minutes Peak effect IV: 4-5 minutes IM: 30-60 minutes IN: ? Butorphanol (Stadol) Duration of action IV: 2-4 hours IM: 3-4 hours IN: ? Stadol dosing IV/IM: 2-4 mg IN: 1-2 mg Ketorolac (Toradol) Nonsteroidal anti-inflammatory agent Can be administered IV or IM Expensive Effective in disorders such as kidney stones and musculoskeletal disorders but is NOT better than opiates in either Dose 30 mg IV or 60 mg IM Ketorolac (Toradol) Few obvious acute side effects (such as hypotension, respiratory depression, emesis) BUT Potentially significant hidden side effects Platelet inhibitor activity can worsen bleeding for up to a week after single injection Renal toxicity (especially in elderly) Before we finish… You can download this Powerpoint from www.jumpstarttriage.com Go to the The Other Dr. Romig page from the home page and click on the appropriate link at the bottom of the page You’re also welcome to any of the other lectures listed. I just ask that appropriate attributions are made if you use them for presentation or research purposes. Please contact me with any questions or corrections. Summary Pain management can and should be a major intervention for prehospital providers There are a number of myths regarding pain management that are being factually debunked But not all healthcare providers are aware or convinced Summary Prehospital pain management CAN be performed safely when appropriate drug choices, protocols, education, documentation and quality management tools are integrated What would you want if YOU or a loved one were the patient in pain? Questions? Laurie A. Romig, MD, FACEP [email protected]