OSF NORTHERN REGION EMERGENCY MEDICAL SERVICES STANDING MEDICAL ORDERS ILS, ALS. SMO: Adult Pain Management

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1 OSF NORTHERN REGION EMERGENCY MEDICAL SERVICES STANDING MEDICAL ORDERS ILS, ALS SMO: Adult Pain Management Overview: Objective: Provide a reasonable relief of severe pain to make packaging and transport more tolerable to the patient. (Both the medical provider and patient need to understand that complete relief of pain in most conditions is not possible.) The goal is to ease severe pain while maintaining the patient s level of consciousness and respiratory status. Conditions: 1) Chest Pain of cardiac nature Refer to Chest Pain SMO 2) Multi-system trauma consider contacting medical control for guidance if significant trauma and Systolic Blood pressure less than or equal to ) Severe burns see burn SMO 4) Significant orthopedic trauma 5) Abdominal Pain must call medical control prior to administering for abdominal pain INFORMATION NEEDED Patient Age Pertinent Medical History Pain Assessment: One of the best pain assessment techniques for gathering and recording information is by the use of the pneumonic O-P-Q-R-S-T: Onset - when did the pain start? Provokes - what brings on the pain? Quality - what does it feel like? Region / Radiation where is it? Where does it go? Severity - how bad is it? (Rated on a consistently used scale) (0-10 grading scale) Pain severity scale is to be assessed and documented both prior to and after interventions. Timing - when did it start/end? How long does it last? How long have you had it? OBJECTIVE FINDINGS General appearance Mental status (AVPU), skin condition, perfusion status Respiratory rate, rhythm and pattern and work of breathing Hemodynamic state Pulse and Blood Pressure Pain severity Scale (1 to 10 scale) both pre and post intervention

2 TREATMENT 1) Baseline care standards. Provide care based on other SMOs related to the patient s presenting complaint. 2) Attempt to manage painful conditions with basic care: Place the patient in a position of comfort. Splint extremity injuries if applicable. If any risk of spine injury, institute spinal immobilization SMO. 3) Administer O 2 15L per minute via non-rebreather mask. If patient not able to tolerate nonrebreather mask, place on nasal cannula. 4) Monitor O2 saturations, and end tidal CO2 if available. 5) The patient must have vital signs taken prior to each dose and be monitored closely, if at any time there is a decreased level of consciousness, decrease in oxygen saturation below 92%, or systolic blood pressure drops to 100 mmhg or less, administration of narcotic medication must stop. 6) For any dosages outside of the SMO, verbal orders must be obtained from medical control. 7) Intranasal administration option indications: when IV access anticipated to be difficult or inability to obtain access; IV access not indicated i.e. isolated orthopedic trauma. Intranasal dosing is different due to differences in absorption and metabolism are different and are listed below. Fentanyl is packaged in 50 ug/ml concentrations. Fentanyl 2 ug/kg (ug= mcg) via intranasal route. Administer half the dose into each nostril 1/3 to 1/2 ml per nostril is recommended but can push up to 1ml per nostril. If weight appropriate dose is more than 2 ml, consider titration with a second dose of the volume that exceeds 2 ml in 5 minutes. Titration to pain is often necessary repeat dosing (1/2 to full dose) every 15 minutes until desired effect is achieved. Maximum 250 ug Naloxone is effective intranasally if you need a reversal agent. Naloxone 2 mg IN with 1/2 the dose to each nostril. When using the MADD device you must give 0.1ml more volume of medication solution as you will have some dead space volume loss from the medication that will remain in the device. If you do not add this extra volume, you will be underdosing the patient. (See chart at end of this SMO) 8) Non-narcotic pain options: Use for patients with narcotic allergies, kidney stones, sprains/strains, isolated extremity trauma, opioid abusers. Do not use in serious trauma patients with significant risk of bleeding, patients with NSAID or aspirin allergies, renal failure, or active peptic ulcer disease or GI bleed. Toradol 30 mg IV for patients age 16 to 65 ( contraindicated for patients less than 16)( If body weight less than 50 kg use 15 mg dose) Toradol 15 mg IV for patients over age 65 9) Narcotic pain options: For patients that have severe pain, and do not have a decreased level of consciousness, and who are hemodynamically stable, and with oxygen saturations above 94% administer: Morphine 0.1 mg/kg IV and then titrate with doses of Morphine 2 mg every 10 minutes until reasonable pain relief to a maximum dose of 10 mg;

3 OR Fentanyl initial dose 100 mcg slow IV then titrate to relief with Fentanyl 50 mcg up to total maximum of 250 mcg Intranasal Fentanyl Dosing Chart: Dosing Plan: Fentanyl concentration - 0.1ml = 5 mcg (50 mcg/ml) Simple calculation: Dose in ml = Wt in Kg x 0.04 plus 0.1 ml dead space Patient weight Fentanyl dose in micrograms (at 2 mcg/kg) Fentanyl volume (including extra 0.1 ml for dead space)* 3-5 kg 10 mcg ml 6-10 kg 20 mcg ml kg 30 mcg ml kg 40 mcg ml kg 50 mcg ml kg 60 mcg ml** kg 70 mcg ml** kg 80 mcg ml** kg 90 mcg ml** kg 100 mcg 2.0 ml** kg 110 mcg ml# kg 120 mcg ml# kg 140 mcg ml# kg 160 mcg ml# kg 180 mcg ml# kg 200 mcg 4.0 ml# You should draw up the additional appropriate dead space of the delivery device you choose. In this table the 0.1 ml represents a typical dead space in a 1 ml syringe connected to a syringe driven atomizer.

4 If patient develops nausea, may give: Zofran 4 mg IV OR Zofran ODT 4 mg Sublingual For signs of narcotic overdosage i.e. respiratory depression or significantly diminished mental status give: Narcan (Naloxone) mg IVP, titrate to maintain adequate spontaneous ventilatory effort (May be given through ET at 2 X the IV dose) Intranasal Naloxone administer 2 mg intranasally, ½ dose to each nostril. May repeat to effect. NOTE: all patient s receiving narcotics and/or Naloxone must be transported to the hospital. Patients who have received narcotics are NOT considered competent to fill out refusal. For patients who receive Naloxone, the coma/depressed respirations may reoccur when the Naloxone wears off. Documentation of adherence to SMO: Indication for SMO use. Patient s presenting signs and symptoms, including vital signs, level of consciousness and oxygen saturation. Oxygen administration and end tidal CO2 if available. Documentation of measures utilized to make patient more comfortable i.e. reassurance, position of comfort, splinting etc. Dose and time for each medication dose used, and resulting clinical effects. Repeat assessment and vital signs, as indicated. Changes from baseline, if any, that occur during treatment or transport. Secure storage of all narcotic medications with mandatory maintenance of narcotic log book Signature and license number of EMT performing care. A second signature is required from another crew member or ED RN, witnessing discarding of unused narcotic. Contact Medical Control prior to administration of any narcotic with abdominal pain or major blood loss and if dose exceeds dose limit. Contact Medical Control whenever a question exists as to the best treatment course for the patient.

5 Security of Narcotics: ALS care providers shall only have access to controlled substances within their scope of practice; BLS care providers shall not have access to controlled substances. All controlled substances shall be secured on the ALS units under a double lock. The units outside driver/passenger/patient access door(s) shall not be considered one of the two locks. The key to access narcotics shall be in the custody of the ALS provider at all times. Each ALS provider agency shall maintain standardized written records of the controlled drug inventory. Those records shall be considered permanent record. Once completed, all drug inventory and administration records shall be maintained in accordance with State and Federal Law and Regulation. ALS care providers assigned to an ALS unit shall be responsible for maintaining the correct daily inventory of narcotics at all times. All controlled substances shall be counted and inspected every time there is a change in the ALS on-duty staff or at a minimum, once a shift. Both the oncoming ALS care provider and the off-going ALS care provider shall jointly count, date, time, and sign the standardized narcotic inventory log. Any discrepancies in the narcotic count shall be reported to the ALS provider supervisor/management and the EMS Medical Director. Medical Control Contact Criteria If any question exists as to the best option for the patient