Why Don’t We Do a Better Job of Treating Pain? Bryan E. Bledsoe, DO, FACEP Midlothian, TX.

transcript

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

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 patients with lower-extremity 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

Femoral neck fractures are among the most common orthopedic injuries encountered in prehospital care.

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

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.

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

Various factors influence the way in which one experiences pain:• Physical• Emotional• Social• Genetic• Age • Cultural

Assessment of Pain

Pain, in most instances, is self-reported.

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

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

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

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

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

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, double-

blind 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):839-40.

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 air-transported 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

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;16:123-7.

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

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

Nitrous Oxide

Supplied as two-cylinder 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

MYTH #1: If I give my patient narcotics, they will not be competent enough to consent for surgery later.

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.

MYTH #2: If I give my patient narcotics for abdominal pain, it will change the physical examination findings, making diagnosis difficult.

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.”

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

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;116:978-983.

MYTH #3: If I give my patient narcotics, they will develop respiratory arrest.

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

MYTH #4: If I give my patient narcotics, they will abuse narcotics

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.

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

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

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):275-80

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 side-effects occurred.

– Silfvast T, Saarnivaara. Comparison of alfentanil and morphine in the prehospital treatment of patients with acute ischaemic-type 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

Study compared 2-cylinder to 1-cylinder 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, double-blinded 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

Why Don’t We Do a Better Job of Treating Pain? Bryan E. Bledsoe, DO, FACEP Midlothian, TX.

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