General Medical: Pain Management

Transcription

1 General Medical: Pain Management Goals: Provide prompt, effective and safe pain relief due to a wide variety of acute injuries and medical illnesses commensurate with pain severity and patient s hemodynamic status; minimize risk of adverse reactions to EMS-administered analgesics Inclusion Criteria: Patients in (acute) pain due to injury and illness, including pain due to sickle cell crisis Exclusion Criteria: Acute ischemic chest pain (refer to Chest Pain CPG); active labor; care plan prohibiting use of parenteral analgesics by EMS; allergy to available analgesics; chronic pain without a palliative/hospice care plan Refer to: Burns, Chest Pain, Hemorrhage Control/Tourniquet Use, OB/Gyn and Trauma CPGs NOTES: Safe and effective acute pain management in the dynamic prehospital environment requires expertise in a range of pharmacologic and non-pharmacologic techniques, as well as sound clinical judgment. Recognition, documentation and adequate treatment of acute pain are critical EMS performance measures. Basic Level 1. Assess and support ABCs according to UNIVERSAL CARE ADULT or UNIVERSAL CARE PEDIATRIC, as clinically indicated: a. A (Airway): Ensure airway patency with suctioning and OPA or NPA, as needed b. B (Breathing): Provide supplemental oxygen to maintain SpO2 at least 94% (continuous monitoring) c. C (Circulation): Assess perfusion, including neurovascular status of injured extremities; initiate continuous ECG monitoring d. D (Disability): Assess and document GCS; assess pupillary size and reactivity e. E (Exposure/Environmental): Assess for trauma, pregnancy and other etiologies 2. Positioning: a. If trauma is not suspected, position the patient in a position of comfort, or in the left lateral decubitus position, facing EMS Providers, in order to monitor and manage the airway: i. If trauma is suspected, refer to the Spinal Motion Restriction Policy and Trauma CPG 3. Perform and document a POC Glucose analysis and treat according to the Diabetic Emergencies CPG a. NOTE: Diabetic Ketoacidosis (DKA) may present with abdominal pain mimicking an acute abdomen 4. Determine the patient s pain score using an age-appropriate standardized pain scale: a. Refer to the Standardized Pain Scales Resource at the end of this CPG b. ADULT and adolescent at least 12 years of age: i. Self-report Numeric Rating Scale (NRS) c. PEDIATRIC patient 4 to 12 years of age: i. Self-report scale (e.g. Wong-Baker FACES Scale or Faces Pain Scale-Revised (FPS-R)) d. INFANT or CHILD less than 4 years of age: i. Observational scale (e.g. FLACC or CHEOPS) 5. Obtain focused history about traumatic and medical causes for acute pain; menstrual history (abdominal pain in women of childbearing age consider ruptured ectopic pregnancy); cardiovascular disease (consider: dissection or aneurysm); sickle cell disease; medication history; medication allergies; other pertinent history 6. If available, consider use of non-pharmaceutical pain management techniques, such as: a. Placement of patient in a position of comfort b. Application of cold packs and/or splints for pain secondary to trauma i. NOTE: Do not use traction splints for patients less than 14 years of age c. Dry, clean dressings to provide partial pain relief for minor, partial-thickness burns d. Verbal reassurance 7. Once advanced level care arrives on scene, give report and transfer care Advanced Level 8. Continue ECG and SpO2 monitoring until patient care has been transferred to hospital staff

2 a. For sickle cell patient with hypoxia, chest pain and fever, consider acute chest syndrome 9. Initiate continuous PetCO2 monitoring if signs/symptoms of shock or hypoperfusion 10. Consider establishing IV/IO access at TKO rate: a. Provide fluid resuscitation as needed, according to underlying etiology: refer to Burns, Hemorrhage Control/Tourniquet, OB/Gyn, Shock, Trauma or other symptom-specific CPGs b. For adult or pediatric patient with acute, sickle cell, vaso-occlusive crisis ( VOC, aka pain crisis ), administer 10 ml/kg NS (1 L maximum per bolus) and assess response: i. Contact BioTel to authorize additional fluid administration 11. For acute pain unrelieved by non-pharmaceutical methods, consider analgesic medications: a. NOTE: Contact BioTel before administering opioid analgesia if patient: i. Is older than 65 years of age; ii. Is debilitated or severely dehydrated; iii. Is hypoxic (SpO2 less than 90%) or hypercarbic (PetCO2 greater than 45 mmhg) iv. Has altered mental status (GCS less than 15); OR v. Has SBP less than 90 mmhg (ADULT) or less than (70 mmhg + (2Xage (years)) (PEDIATRIC) b. ADULT at least 14 years of age: i. Fentanyl: 1 mcg/kg slow IVP/IO/IM/IN (maximum single dose: 100 mcg) 1. May repeat once after 10 minutes, if incomplete response 2. Do not exceed 200 mcg total, cumulative dose without BioTel authorization; OR ii. Morphine: 2 to 4 mg slow IVP/IO/IM 1. May repeat every 10 minutes, if incomplete response 2. Do not exceed 8 mg total, cumulative dose without BioTel authorization c. PEDIATRIC patient less than 14 years of age (monitor for cardiorespiratory depression): i. Fentanyl: 1 mcg/kg slow IVP/IO/IM/IN (maximum single dose: 100 mcg) 1. May repeat once after 10 minutes, if incomplete response 2. Do not exceed 200 mcg total, cumulative dose without BioTel authorization; OR ii. Morphine: 0.05 mg/kg slow IVP/IO/IM (maximum single dose: 2 mg) 1. Do not exceed 4 mg total, cumulative dose without BioTel authorization 12. For severe pain unrelieved by opioid analgesics, and for use only by appropriately trained EMS Providers in agencies with Medical Director authorization, consider IN or IM ketamine as an adjunct analgesic: a. NOTE: The 100 mg/ml concentration of ketamine hydrochloride should NOT be injected IV or IO b. NOTE: Be prepared for respiratory depression, laryngospasm or apnea; excessive salivation; hallucinations, agitation or emergence reaction; nausea or vomiting; tachycardia or hypertension c. ADULT at least 14 years of age: i. Ketamine IN or IM: 0.5 mg/kg (maximum single dose: 25 mg) 1. May repeat once after 10 minutes, up to a maximum, cumulative, total dose of 100 mg ii. Ketamine IV/IO for analgesia: NOT authorized in the BioTel system at this time d. PEDIATRIC patient less than 14 years of age: i. Ketamine IM or IN: 0.5 mg/kg (maximum single dose: 25 mg) 1. May repeat once after 10 minutes, up to a maximum, cumulative, total dose of 100 mg ii. Ketamine IV/IO for analgesia: NOT authorized in the BioTel system at this time 13. Detailed documentation of the patient s response to pain management interventions is a critical EMS performance measure (refer to the Standardized Pain Scales Resource on the next page) 14. Consider ondansetron or promethazine to treat opioid-induced nausea/vomiting 15. Special circumstances (treat according to the applicable, symptom-specific CPG): a. Abdominal pain: Consider acute appendicitis/diverticulitis/pancreatitis or other infectious/inflammatory etiologies; leaking or ruptured abdominal aortic aneurysm; pregnancy-related complications; analgesia administration does not mask physical findings or delay diagnosis b. Atypical, non-traumatic chest pain: Consider aortic dissection, pulmonary embolism and other, nonischemic etiologies c. Flank pain: Consider kidney stone, pyelonephritis d. Back pain: Consider dissection or aneurysm; herniated intervertebral disk 16. For patient care considerations not covered under standing orders, consult BioTel Refer to the Standardized Pain Scale Resource on the next pages

3 Standardized Pain Scales Resource ADULT (at least 12 years of age) Universal Pain Assessment Tools Self-Report Numerical Rating Scale (NRS) Descriptive, Observational Scale

4 CHILD 4 to 12 years of age Wong-Baker FACES Pain Rating Scale reproduced with permission from OR Faces Pain Scale-Revised (FPS-R) reproduced with permission from

5 Categories Face Legs Activity Cry Consolability INFANT and CHILD less than 4 years of age Observational Scales Face, Legs, Activity, Cry, Consolability (FLACC) Pain Assessment Tool Scoring Occasional grimace or frown, withdrawn, disinterested No particular expression or smile Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or asleep) Content, relaxed Uneasy, restless, tense Squirming, shifting back and forth, tense Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or being talked to, distractible Frequent to constant frown, clenched jaw, quivering chin Kicking, or legs drawn up Arched, rigid or jerking Crying steadily, screams or sobs, frequent complaints Difficult to console or comfort Category Score Total Score (Range = 0 to 10 points) Excerpted from: Merkel SI et al (1997).The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nursing 23(3): Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self-report is not possible, interpretation of pain behaviors and decision-making regarding treatment of pain requires careful consideration of the context in which the pain behaviors were observed. Assessment of behavioral score: 0 = Relaxed and comfortable 1 to 3 = Mild discomfort 4 to 6 = Moderate pain 7 to 10 = Severe discomfort/pain OR Children s Hospital of Eastern Ontario Pain Scale (CHEOPS) Parameter Scoring Cry No cry Moaning or crying Screaming Facial Smiling Composed Grimace Child Verbal Positive Pain complaints or None or complaints both pain and nonpain complaints other than pain Shifting, tense, Torso Neutral shivering, upright or restrained Touch Not touching Reach or touch or grab or restrained Squirming, kicking, Legs Neutral drawn up, tensed, standing or restrained Total Score (Range = 4 to 13 points) Category Score McGrath PJ Johnson G et al (1985). CHEOPS: A behavioral scale for rating postoperative pain in children. Adv Pain Research Therapy. 9: Available online at MDCalc.com: CHEOPS Assessment of score: Consider analgesia if score is 5 or more