Download Why Don`t We Do a Better Job of Treating Pain?

Why Don’t We Do a Better Job
of Treating Pain?
Bryan E. Bledsoe, DO, FACEP
Midlothian, TX
Introduction

Many, if not most,
medical conditions
cause pain.
Introduction

Pain is a protective
mechanism and
occurs whenever
any tissues of the
body are being
damaged.
Introduction

Pain occurs
whenever the cells
or tissues are being
damaged—
whatever the
underlying cause.
Introduction

The reaction to
pain may be rapid,
as seen when one
touches a hot pan.
Introduction

Or slow, as when
one has been
seated in the
same position for
an extended
period of time.
Introduction

It is for this reason
that persons with
spinal cord injuries
are at risk for
developing
decubitus ulcers.
Introduction

Because of their
injury, they:
• Cannot sense pain
from the pressure
area.
• Cannot move to
eliminate the
pressure.
• Or a combination
of both.
Introduction

One of the oldest
roles of medical
practitioners is to
help alleviate pain.
Introduction

Analgesia
• The relief of pain without a loss of
consciousness.
Introduction

Analgesia can be provided by:
•
•
•
•
Drugs
Surgical Procedures
Physical Modalities
Other
Introduction

Analgesia:
• Eliminate the source of the pain.
• Block or attenuate the pathways that
transmit pain impulses to the brain.
• Combination of the two.
Introduction

Pain elicits a strong
emotional response
that is often
recorded in our
memory.
Introduction

“Lest we be like the
cat that sits down on
a hot stove-lid. She
will never sit down
on a hot stove-lid
again—and that is
well; but also she
will never sit down
on a cold one
anymore.”
Problems in Pain Management
Problems

Pain appears to be under treated:
•
•
•
•
Failure to assess pain.
Failure to quantify pain.
Fear of addiction.
Legal constraints of utilizing controlled
substances.
• Ignorance
Problems

UCLA Medical Center Study:
• Hispanic patients with isolated long-bone
fractures were twice as likely to receive
NO pain medication when compared to
their non-Hispanic white counterparts.
– Todd KH, Samaroo N, Hoffman JR. Ethnicity
as a risk factor for inadequate emergency
department analgesia. JAMA.
1993;269(10):1537-9
Problems

Grady Memorial Hospital:
• Black patients with isolated long-bone
fractures were less likely to receive
adequate analgesia when compared to
their white counterparts.
– Todd KH, Deaton C, D’Adamo AP, Goe L.
Ethnicity and analgesic practice. Ann Emerg
Med. 2000;35(1):11-16
Problems

Nationwide survey of burn patients:
• Only half of burn patients treated in
emergency departments received
adequate analgesia for their burn pain.
– Singer AJ, Thode HC Jr. National analgesia
prescribing patterns in emergency department
patients with burns. J Burn Care Rehabil.
2002;23(6):361-5
Problems

EMS Study (Pediatrics)
• Few pediatric patients receive prehospital
analgesia, although most ultimately
received ED analgesia.
– Swor R, McEachin CM, Sequin D. Grall KH.
Prehospital pain management in children
suffering traumatic injury. Prehospital Emergency
Care. 2005;9(1):40-43
Prehospital Pain
Management is even worse!
Prehospital Pain Management

Pain in the prehospital setting is often:
• Not identified,
• Under treated,
• Both.
– Ricard-Hibon A, Leroy N, Magne M, et al.
Evaluation of acute pain in prehospital
medicine. Ann Fr Anesth Reanim.
1997;16(8):945-9
Prehospital Pain Management

Patients with extremity fractures
receive inadequate analgesia.
• Study of 1,073 patients found only 1.5%
received analgesia in the prehospital
setting.
– White LJ, Cooper LJ, Chambers RM,
Gradisek RE. Prehospital use of analgesia for
suspected extremity fractures. Prehosp
Emerg Care. 2000;4(3):205-8
Prehospital Pain Management

Prehospital patients with lowerextremity fractures (including hip
fractures):
• Only 18.3% of eligible patients received
analgesia.
– McEachin CC, McDermott JT, Swor R. Few
emergency medical services patients with
lower extremity fractures receive prehospital
analgesia. Prehosp Emerg Care.
2002;6(4):406-410
Prehospital Pain Management

Femoral neck
fractures are among
the most common
orthopedic injuries
encountered in
prehospital care.
Prehospital Pain Management

Hip fractures:
• Only a modest proportion of these
patients receive prehospital analgesia for
this painful and debilitating injury.
– Vassiliadis J, Hitos K, Hill CT. Factors
influencing prehospital and emergency
department analgesia administration to
patients with femoral neck fractures. Emerg
Med (Fremantle). 2002:14(3):261-6
Prehospital Pain Management

Nothing is more cruel than:
• Retrieving elderly patient with isolated hip
fracture.
• Tying them to a sheet of plywood or plastic.
• Wrapping a hard collar around their arthritic
neck.
• Placing them in a 2-ton truck.
• Driving them to the hospital over rough roads.
Prehospital Pain Management

Without adequate analgesia!
What is Pain?
A sensory or emotional experience or
discomfort.
 Single, most common medical
complaint.

Qualities of Pain
Organic versus Psychogenic
 Acute versus Chronic
 Malignant versus Benign
 Continuous versus Episodic

Types of Pain

Acute pain:
• Pain associate with an acute event

Chronic pain:
• Pain that persists after an acute event is
over
• Pain that last 6 months or more
Pathophysiology of Pain
Pathophysiology

The generation of
pain involves
interaction
between all parts
of the nervous
system.
Pathophysiology
Significant strides have been made as
to how the body senses and interprets
pain over the last 2 decades.
 Pain-generation pathways more
clearly understood.
 Chronic pain better understood.

Pathophysiology
Pain is more than a just a feeling or
sensation, but linked to the complex
psychosocial factors that surround
traumatic events.
 Pain is the brain’s interpretation of the
painful stimulus.

Pathophysiology

Perceiving pain:
• Algogenic substances—chemicals
released at the site of injury.
• Nociceptors—Afferent neurons that carry
pain messages.
• Referred pain—pain that is perceived as
if it were coming from somewhere else in
the body.
Pathophysiology

Nociception
• Derived from the word noxious meaning
harmful or damaging to the tissues.
• Mechanical event that occurs in tissues
undergoing cellular injury.
Pathophysiology
Nociceptive stimulus is detected by
free nerve endings in the tissues.
 Three type of stimuli excite pain
receptors:

• Mechanical
• Thermal
• Chemical
Pathophysiology

Pain fibers are free
fibers.
Pathophysiology
Pain fibers principally located in the
superficial layers of the skin.
 Pain fibers also located in:

•
•
•
•
Periosteum
Arterial walls
Joint surfaces
Falx and tentorium of the cranial vault.
Pathophysiology

Deep structures:
• Sparsely supplied with pain fibers
• Widespread tissue damage still causes
the slow, chronic, aching-type pain.
Pathophysiology

Visceral Pain:
• Ischemia
• Chemical stimuli
• Spasm of hollow
viscus
• Over distension of a
hollow viscous
Pathophysiology

Chemicals that excite pain receptors:
•
•
•
•
•
•
•
Bradykinin
Serotonin
Histamine
Potassium ions
Acids
Acetylcholine
Proteolytic enzymes
Pathophysiology

Chemicals that enhance the sensitivity
of pain endings, but do not necessarily
excite them:
• Prostaglandins
• Substance P
Pathophysiology

Types of pain:
• Fast Pain:
– Felt within 0.1 second after painful stimulus
– Also called: sharp pain, pricking pain, electric
pain and acute pain.
– Felt with needle stick, laceration, burn
Pathophysiology

Types of pain:
• Slow Pain:
– Felt within 1.0 second or more after painful
stimulus
– Also called: dull pain, aching pain, throbbing
pain and chronic pain.
– Usually associated with tissue destruction
Pathophysiology

Pain fibers transmit impulse to spinal
cord through fast or slow fibers:
• A-δ (delta) fibers—small myelinated
fibers that transmit sharp pain.
• C fibers—small unmyelinated fibers that
transmit dull pain or aching pain.
Pathophysiology

Pain is often a “double” sensation as
fast pain is transmitted by the Aδ
fibers while a second or so later it is
transmitted by the C fiber pathway.
Pathophysiology
Pain impulses enter the spinal cord
from the dorsal spinal nerve roots.
 Fibers terminate on neurons in the
dorsal horns.

Pathophysiology

Impulses then transmitted to the brain
via the lateral spinothalamic tract
Pathophysiolgy

Pain ultimately transmitted to:
• Thalamus
• Medulla oblongata
• Somatosensory areas of the cerebral
cortex.
Analgesia

The brain’s opiate
system:
• Endorphins
• Enkephalins
Referred Pain

The sensation of
pain in a region that
is remote from the
tissue causing the
pain.
Referred Pain

Certain referred
pain patterns are
recognized.
Assessment of Pain
Assessment of Pain

Various factors influence the way in
which one experiences pain:
•
•
•
•
•
•
Physical
Emotional
Social
Genetic
Age
Cultural
Assessment of Pain
Pain, in most instances, is selfreported.
 This should be considered along with
physical signs and symptoms when
assessing pain.

Assessment of Pain

Factors that affect assessment:
•
•
•
•
•
Developmental stage
Chronological age
Cognitive ability
Emotional status
Cultural influence
Assessment of Pain

Self-Report of pain:
• Have patient describe how they feel.
• For infants and children, rely on care
givers.
• Obtain important historical information
OPQRST-ASPN System








Onset of Problem
Provocative / Palliative factors
Quality
Region / Radiation
Severity
Time
Associated Symptoms
Pertinent Negatives
Assessment of Pain

Behavioral Observations:
•
•
•
•
Vocalizations (cry, scream, moan)
Facial expressions (frown, grimace)
Body posture (fetal position)
Motor responses (decreased movement,
restlessness)
Assessment of Pain

Physiological measurements:
•
•
•
•
•
•
Skin flushing
Diaphoresis
Restlessness
Tachycardia
Tachypnea
Elevated BP
Assessment of Pain

Physical
examination will
often give a clear
indication of the
source of the
patient’s pain.
Assessment of Pain

How do you
quantify pain?
Infants
Neonatal Infant Pain Scale (NIPS)
 CRIES:

•
•
•
•
•
Crying
Requires oxygen to maintain sat > 95%
Increased vital signs
Expression
Level of Sleep
Children 1-7 years

CHEOPS (Children’s Hospital of
Eastern Ontario Pain Scale):
•
•
•
•
•
•
Cry
Facial
Child verbal
Torso
Touch
Legs
Children > 3 years

Wong-Baker FACES Scale:
Adult Pain

“Ten Scale” most common:
• 11 point scale
• 0 = No pain
• 10 = Worst pain imaginable
Adult Pain

Visual “Ten Scale”:
Adult Pain

Word / Graphic Scale:
Adult Pain

Multiple Assessment Tool:
Pain Management
Pain Management

Priorities are priorities!
•
•
•
•
Scene safety
BSI
Treat any life-threatening illness of injury
Treat pain
Pain Management

Strategies:
• Removing or
correcting the source
of the pain
Pain Management

Strategies:
• Blocking or
attenuating the
transmission of pain
impulses to the brain
Pain Management

Strategies:
• Or, a combination of
both
Pain Management

Non-medication therapies:
•
•
•
•
•
•
•
Recognition and empathy
Distraction
Muscle relaxation
Position of comfort
Temperature regulation
Physical therapies
Treat underlying cause
Pain Management

RICE:
•
•
•
•
Rest
Ice
Compression
Elevation
Pain Management
Medications that relieve pain are
called analgesics
 Medication therapies:

• Peripherally-acting agents
• Centrally-acting agents
Pain Management

Peripherally-acting agents
• Considerable reaction locally to cellular
and tissue damage:
– Pain
– Swelling
– Inflammation
Pain Management
Pain Management

Peripherally-acting agents:
• Corticosteroids
• Non-steroidal anti-inflammatory agents
(NSAIDs)
• Local Anesthesia
Pain Management

Peripherally-acting agents:
•
•
•
•
Methylprednisolone
Acetaminophen
Ibuprofen
Aspirin
Pain Management

NSAIDs
• Effective for pain and inflammation
• Good side-effect profile
• Second generation NSAIDs have better
side-effect profiles
• Inhibit prostaglandins and other
mediators of pain and inflammation
Ketorolac (Toradol)


Only injectable
NSAID in the US
Analgesic,
antipyretic and
anti-inflammatory
properties.
Ketorolac (Toradol)
Used for moderate-severe pain
 Orthopedic and soft-tissue injuries
 Popular for ureteral colic.
 Often used in conjunction with
centrally-acting agents such as
morphine.

Ketorolac (Toradol)
Onset of action: < 30 minutes IV
 Peak effects: 45-60 minutes
 Duration: 4-6 hours
 Typical IV dose: 30 mg

Pain Management

Centrally-acting agents:
• Opiates
• Anesthetic gasses used in analgesic
quantities
• Atypical agents (ketamine)
Opiates



Mainstay of
analgesic practice
Originally derived
from the opium
poppy plant
Many now
synthetically
manufactured
Opiate Receptors
Μu (μ ) receptors
 Kappa (κ) receptors
 Delta (δ) receptors
 Actions:

•
•
•
•
Inhibit pain
Cause sedation
Respiratory depression
Cardiovascular depression
Opiates

Actions:
• Act on CNS and organs containing
smooth muscle
• Analgesia without loss of consciousness
Opiates

Effects:
•
•
•
•
•
•
•
•
Analgesia
Suppresses cough reflex
Respiratory depression
Mental clouding
Mood changes
Euphoria
Dysphoria
Nausea and vomiting
Opiates

Effects:
• Meiosis
• Decreased gastric, biliary and pancreatic
secretions
• Reduce gastric motility
• Delay digestion of food in the small
bowel
• Decreases peristalsis in the colon
(constipation)
Opiates

Effects:
• Certain opiates (morphine) cause an
increase in biliary tract pressure
• Certain opiates (morphine) cause
peripheral vasodiation
• Histamine release (red eyes, pruritis,
flushing)
Opiates

Morphine
Morphine

Named after Greek
god Morpheus—god
of sleep and dreams
Morphine
Occurs naturally in the poppy plant
 Among the most frequently used
opiates in emergency medicine
 Used for moderate to severe pain
 Vasodilator for CHF and pulmonary
edema

Morphine
Onset of action: < 5 minutes IV
 Peak effects: 20 minutes
 Duration: 7 hours
 Typical IV dose: 2.5-10.0 mg

Opiates

Meperidine
(Demerol)
Meperidine
Synthetic opiate—chemically
unrelated to morphine
 1/10 as potent as morphine
 Tends to cause more histamine
release than morphine and thus more
side-effects

Meperidine
Causes more euphoria than other
agents
 Now removed from many EDs and
EMS services due to abuse and
the availability of better drugs

Meperidine
Onset of action: < 5 minutes IV
 Peak effects: < 30 minutes
 Duration: 2 hours
 Typical IV dose: 25-100 mg

Opiates

Hydromorphone
(Dilaudid)
Hydromorphone




Synthetic opiate
Effective for moderate
to severe pain
8-10 times more
potent than morphine
Reportedly produces
less nausea and
vomiting than
morphine
Hydromorphone
Onset of action: < 5 minutes IV
 Peak effects: 30-90 minutes
 Duration: 4-5 hours
 Typical V dose: 1-4 mg

Opiates

Fentanyl
(Sublimaze)
Fentanyl
Synthetic opiate—chemically
unrelated to morphine
 Initially an anesthetic induction agent
 Short-acting
 Pharmacological effects similar to that
of morphine
 Better side-effect profile because of
short duration of action.

Fentanyl

Less histamine release than morphine
• Sivilotti ML, Ducharme J. Randomized, doubleblind study on sedatives and hemodynamics
during rapid-sequence intubation in the
emergency department: The SHRED Study. Ann
Emerg Med. 1998;31(3):125-6.
Fentanyl

Now routinely used in emergency
medicine and, to a lesser degree, in
EMS
– Chudnofsky CR, Wright SW, Dronen SC, et al.
The safety of fentanyl in the emergency
department. Ann Emerg Med. 1989;18(6):83940.
Fentanyl

Used in multiple trauma patients
because of hemodynamic profile.
– Walsh M, Smith GA, Yount RA, et al.
Continuous intravenous infusion for sedation
and analgesia of the multiple trauma patient.
Ann Emerg Med. 1991;20(8):913-5.
Fentanyl
Proven effective in the prehospital
(air medical) treatment of pediatric
trauma patients.
 No untoward effects during 5 years of
prehospital use

– Devellis P, Thomas SH, Wedel SK, et al.
Prehospital fentanyl analgesia in airtransported pediatric trauma patients.
Pediatr Emerg Care. 1998;14(5):321-3.
Fentanyl
Onset of action: Immediate IV
 Peak effects: 3-5 minutes
 Duration: 30-60 minutes
 Typical IV dose: 25-100 μgs

Opiates

Synthetic opiate agonists / antagonists
• Nalbuphine
• Butorphanol
Synthetic Mixed Opiates
Sub-class of opiates with both
agonistic and antagonistic property
 Activate some opiate receptors while
blocking others
 Reportedly decreases the likelihood of
abuse and respiratory depression
 Not controlled in many states

Synthetic Mixed Opiates

Nalbuphine
(Nubain)
Nalbuphine
Most common mixed agent used in
prehospital care
 Antagonistic properties decrease the
potential for abuse.

Nalbuphine

Initial studies indicated it was an
effective alternative to morphine.
– Chambers JA, Guly HR. Prehospital
intravenous nalbuphine administered by
paramedics. Resuscitation. 1994;27-153-8.
– Stene JK, Stofberg L, MacDonald G, et al.
Nalbuphine analgesia in the prehospital
setting. Am J Emerg Med. 1988;6(6):634-9.
Nalbuphine
Subsequent studies seem to suggest
not as effective as once thought.
 English study found it offered poor
pain control to a high proportion of
patients in the prehospital setting.

– Wollard M, Jones T, Vetter N. Hitting them
where it hurts? Low dose nalbuphine
therapy. Emerg Med J 2002;19:565-570.
Nalbuphine

Because of antagonistic properties,
prehospital nalbuphine usage
appears to be responsible for
increased opiate requirements once
patients arrive in the ED.
– Houlihan KPG, Mitchell RG, Flapan AD, et al.
Excessive morphine requirements after
prehospital nalbuphine analgesia. J Accid
Emerg Med 1999;16:29-31
Nalbuphine

Also appears to interfere with general
anesthesia and maintenance.
– Robinson N, Burrow N. Excessive morphine
requirements after pre-hospital nalbuphine
analgesia. J Accid Emerg Med. 1999;16:1237.
Nalbuphine

Probably should have a limited role in
emergency medicine and EMS.
Nalbuphine
Onset of action: 2-3 minutes IV
 Peak effects: < 30 minutes
 Duration of effect: 3-6 hours
 Typical IV dose: 5-20 mg

Synthetic Mixed Opiates

Butorphanol
(Stadol)
Butorphanol




Used by a few EMS
systems
Similar properties to
nalbuphine
Role in EMS has not
been widely studied
Probably should have
a limited role in EMS
Butorphanol


Thought to be
non-addictive.
Stadol NS resulted
in significant
addictions
Butorphanol
Onset of action: < 1 minute IV
 Peak effects: 3-5 minutes
 Duration: 2-4 hours
 Typical IV dose: 0.5-2.0 mg

Gasses

Nitrous Oxide (N2O):
•
•
•
•
•
Anesthetic at high concentrations
Analgesic at low concentrations
Initially used in dentistry and obstetrics
Introduced into EMS in the 1970s.
Effective in treating virtually all types of
pain.
Nitrous Oxide


Supplied as twocylinder device
(Nitronox) that
feeds gases into a
blender at 50:50
concentration
Self-administered
through modified
demand valve.
Nitrous Oxide

Proven effective in numerous types of
pain encountered in the prehospital
setting.
– Stewart RD, Paris PM, Stoy WA, Cannon G.
Patient-controlled inhalation analgesia in
prehospital care: a study of side-effects and
feasibility. Crit Care Med. 1983;11(11):851-5.
– Pons PT. Nitrous oxide analgesia. Emerg Med
Clin North Am. 1988;6(4):777-82,
Nitrous Oxide

Effective for painful procedures such
as transcutaneous pacing.
– Kaplan RM, Heller MB, McPherson J, Paris
PM. An evaluation of nitrous oxide analgesia
during transcutaneous pacing. Prehosp
Disaster Med. 1990;5(2):145-9.
Nitrous Oxide

NAEMSP has issued a detailed
position statement regarding it’s use.
– National Association of EMS Physicians. Use
of nitrous oxide:oxygen mixtures in prehospital
emergency care. Prehosp Disaster Med.
1990;5(3):273-4.
Nitrous Oxide

Probably underutilized for several
reasons:
•
•
•
•
Cost
Bulky delivery system
Storage issues
Lack of understanding regarding efficacy
Myths of Pain Management
Myths of Pain Management
MYTH #1: If I give my patient
narcotics, they will not be
competent enough to consent for
surgery later.
Myths of Pain Management

Myth # 1: FALSE
• Concern about rendering patient
incompetent is unfounded.
• Withholding analgesia can be looked
upon as a form of “coercion” to sign
consent for surgery.
– Gabbay DS, Dickenson ET. Refusal of base
station physicians to authorize narcotic
analgesia. Prehosp Emerg Care.
2001;3(5):293-5.
Myths of Pain Management

MYTH #2: If I give my patient
narcotics for abdominal pain, it will
change the physical examination
findings, making diagnosis
difficult.
Myths of Pain Management

Myth # 2: False
• The dogma of withholding analgesia for fear that
it will alter an abdominal examination stems
from the 1921 book by Dr. Zachary Cope
entitled Early Diagnosis of the Acute Abdomen
that stated, “If morphine be given, it is possible
for a patient to die happy in the belief that he is
on the road to recovery, and in some cases the
medical attendant may for a time be induced to
share the elusive hope.”
Myths of Pain Management

Myth # 2: False
• Several researchers have examined this question:
– Patients with abdominal pain randomly assigned to receive
either IV morphine or saline.
– Patients were assessed before and after the morphine or
saline was administered, and then assessed later by a
surgeon if indicated.
– The presence of peritoneal signs did not change in the
group that received morphine and the accuracy of diagnosis
did not differ between the two groups of patients as well as
between the emergency physicians and the surgeons.
– In fact, there was also a trend that the examination may be
more reliable after treatment with morphine.
– Pace S, Burke TF. Intravenous morphine for early pain
relief in patients with acute abdominal pain. Acad.
Emerg. Med. 1996;3:1086–1092
Myths of Pain Management

Myth # 2: False
• 108 children with abdominal pain.
– 52 morphine
– 56 placebo (saline)
• Groups well matched.
• Morphine effectively reduces the intensity of [ain
and does not seem to impede the diagnosis of
appendicitis.
– Green R. et al. Early analgesia for children with
acute abdominal pain. Pediatrics. 2005;116:978983.
Myths of Pain Management

MYTH #3: If I give my patient
narcotics, they will develop
respiratory arrest.
Myths of Pain Management

Myth # 3: False
• Respiratory depressant effects often
offset by sympathetic stimulation in the
pain patient.
• Different than from respiratory
depression in pain-free opiate addicts.
• Key is to use correct analgesic dose
Myths of Pain Management

MYTH #4: If I give my patient
narcotics, they will abuse narcotics
Myths of Pain Management

Myth # 4: False
• Because a few patients malinger and
drug-seek is no reason to withhold from
legitimate pain patients.
• Addicts need analgesia on occasion too.
• Most people who become addicted to
pain killers have underlying addictive
tendencies.
Myths of Pain Management

Myth # 4: False
• In a 5-year review, the medical use of
opiates increased while the incidence of
opiate abuse actually decreased.
– Joranson DE, Ryan KM, Gilson AM, Dahl JL.
Trends in medical use and abuse of opioid
analgesics. JAMA. 2000;283(13):1710-4.
Future Trends in Prehospital
Pain Management
Future Trends
Methoxyflurane Inhalers
 Intranasal fentanyl
 Alfentanil (Alfenta)
 Tramadol (Ultram)
 Entonox
 Non-Pharmacological interventions

Methoxyflurane


Inhalation
anesthetic with
potent analgesic
properties at low
doses.
Highly-volatile
liquid
Methoxyflurane

Came to attention
of US EMS people
after reality-based
series Survivor
Methoxyflurane

Widely used
throughout
Australia in EMS
and in Defence
forces.
Methoxyflurane
Methoxyflurane has a fruity smell that
is well-tolerated by patients
 Administered via a methoxyflurane
(Penthrane or Penthrox) inhaler

Methoxyflurane
Methoxyflurane
3 mL of methoxyflurane are placed
onto the wick of the inhaler
 Device gently shaken and any excess
wiped off
 Inhaler given to patient to self
administer
 Supplemental oxygen can be
provided.

Methoxyflurane
Pain relief usually begins in 8-10
breaths
 Lasts for 25-30 minutes
 Allows time for IV access and
morphine
 Should be used in well ventilated
area.

Methoxyflurane

Why don’t we have it?
• Methoxyflurane limited to animal use in
US.
• Reported liver and kidney toxicity (in
anesthetic doses—not analgesic doses)
• US manufacturer quit making Metofane
• Commonwealth of Australia considers
the drug safe for analgesic usage
Intranasal Fentanyl
Australian study has shown intranasal
fentanyl safe and effective in treating
trauma pain in children between 3-12
years of age.
 Children 3-7: 20 μg IN
 Children 8-12: 40 μg IN
 Additional 20 μg doses q 5 minutes

Intranasal Fentanyl
Allowed for early and significant
reduction in pain.
 Shows great promise for emergency
medicine and EMS

– Borland ML, Jacobs I, Geelhoed G. Intranasal
fentanyl reduces acute pain in children in the
emergency department: a safety and efficacy
study. Emerg Med (Fremantle). 2002;14(3):27580
Alfentanil (Alfenta)


Chemical
analogue of
fentanyl (shorter
acting)
Less side-effects
than morphine
Alfentanil (Alfenta)
Faster, more effective pain relief
when compared to morphine.
 No hemodynamic or respiratory sideeffects occurred.

– Silfvast T, Saarnivaara. Comparison of
alfentanil and morphine in the prehospital
treatment of patients with acute ischaemictype chest pain. Eur J Emerg Med.
2001;8(4):275-8.
Tramadol




Synthetic
analogue of
codeine.
Has weak opioid
agonistic
properties.
Slight abuse
potential
Non-controlled
Tramadol
Parenteral form not yet available in
US
 1/10 as potent as morphine
 Onset of action: 1-5 minutes IV
 Peak effects: 15-45 minutes
 Duration:
4.5 hours
 Typical IV dose: 100 mg

Tramadol
Analgesia and side-effects similar to
morphine.
 Concluded tramadol is an effective
alternative to morphine in the
prehospital setting.

– Vergnion M, Desgesves S, Garcey L,
Magotteaux V. Tramadol, an Alternative to
Morphine for Treating Posttraumatic Pain in
the Prehospital Situation. Anest Analg.
2001;92:1543-6.
Entonox
Single-cylinder pre-mixed 50:50
nitrous oxide oxygen mixture.
 Available everywhere but the US.
 Gasses tend to separate ~ 26° F (but
remix with inversion of cylinder)
 Cheaper, less bulky,

Entonox
Entonox
Study compared 2-cylinder to 1cylinder system.
 Nitronox safer in cold weather
 No significant clinical differences
overall

– McKinnon KD. Prehospital analgesia with
nitrous oxide/oxygen. Can Med Assoc J.
1981;125:836-840
Entonox

Entonox preferred
over Nitronox by
prehospital
personnel involved
in study.
Non-Pharmacological
Interesting Austrian study for victims
of minor trauma using acupressure.
 Patients randomly assigned to receive
acupressure at “true points,” at “sham
points” or “no acupressure.”
 Different values measured before and
after treatment.

Acupressure


At the end of transport, patients who
received acupressure at “true points” had
less pain, less anxiety, a slower heart rate,
and greater satisfaction with the care
provided.
They concluded that acupressure is an
effective and easy-to-learn treatment of
pain in prehospital care.
– Kober A, ScheckT, Greher M et al. Prehospital
analgesia with acupressure in victims of minor
trauma: a prospective, randomized, doubleblinded trial. Anest Analg. 2002;95(3):723-7.
Summary

How can we improve prehospital pain
control?
• All personnel should assess for the
presence and severity of pain.
• Use objective pain measures
• Medical directors need to become more
aggressive in pain management
Summary


Move prehospital pain management
decisions for most conditions from on-line
medical control to standing orders.
Time to morphine administration decreased
by 2.3 minutes when this change made.
– Fullerton-Gleason L, Crandall C, Sklar DP.
Prehospital administration of morphine for isolated
extremity injuries: a change in protocol reduces
time to medication. Prehosp Emerg Care.
2002;6(4):411-6
Summary

Liberalization of prehospital pain
protocols resulted in increased usage
with no apparent safety or misuse
issues.
– Pointer JA, Harlan K. Impact of liberalization of
protocols for the use of morphine sulfate in an
urban EMS system. Prehospital Emergency
Care. 2005;9(4):377-381
Summary


Field personnel, EMS physicians,
administrators, and representatives from
receiving hospitals should organize a
comprehensive plan to assure that we are
providing adequate analgesia in the
prehospital setting.
EMS is a compassionate profession and
compassion begins with the relief of pain
and suffering