Paramedic controlled analgesia

Over the past several years many papers have been published about various aspects of prehospital analgesia (http://wp.me/P2N7pf-k) and of inadequate analgesia for acute pain (oligoanalgesia). A recent study by Walsh et al. (Prehosp Emerg Care. 2013 Jan;17(1):78-87) again addresses paramedic attitudes regarding prehospital analgesia in a qualitative study using a grounded theory methodology.  The identified the following major themes in their study: 1) a reluctance to administer opioids to patients without significant objective signs (e.g., deformity, hypertension); 2) a preoccupation with potential malingering; 3) ambivalence about the degree of pain control to target or to expect (e.g., aiming to “take the edge off”); 4) a fear of masking diagnostic symptoms; and 5) an aversion to aggressive dosing of opioids (e.g., initial doses of morphine did not exceed 5 mg).  The study authors conclude “A number of potentially modifiable attitudinal barriers to appropriate pain management were revealed”.

Delivering better pain management should be a major focus for all paramedics and emergency paramedic services in 2013 and beyond.  From my perspective the key barriers to providing effective prehospital analgesia include:

1.      Paramedics do not adequately assess initial pain
2.      Paramedics do not believe the patient’s reported experience of pain
3.      Physicians limit analgesic options for paramedics
4.      Policy or legal issues preclude prehospital use of analgesia
5.      Patient factors

What should the goal of prehospital analgesia be?

  1. All patients who report pain get analgesia
  2. Patients are pain free on arrival at ED (or patient does not want further analgesia)
  3. Patients are not harmed by prehospital analgesic regimes

How can we prevent prehospital oligoanalgesia?

Paramedics can routinely assess pain in all patients

  • Assessment of pain is poorly done by paramedics – some research reports < 50% of patients
  • It would be hard to find an easier thing to incorporate into your routine clinical practice.  Common pain assessment tools include:

Verbal numerical rating scale (VNRS) (0=no pain, 10=worst possible pain)
Visual analogue scale (VAS) (0 mm = no pain, 100mm = worst possible pain)
Verbal descriptor scale (e.g. Nil, mild, moderate, severe)
Wong-Baker FACES Pain Rating Scale
“Do you have pain? Would you like pain medicine? [see below]”

Paramedics can believe patient reports of pain

  • Pain is a common reason for seeking emergency paramedic services
  • Patients expect the relief of pain
  • Significant harm from believing the patient is unlikely
  • The majority of patient who report pain have pain
  • If the patient reports pain then give analgesia and reassess the patient’s reported experience of pain
  • Patients can have severe pain without significant alterations in vital signs
  • Paramedics can improve the documentation of pain
    • Initial and final pain scores should be mandatory (and truthful)
    • Pain scores must be patient reported (not paramedic reported)
    • Independent assessment of pain at triage would help inform ED management as ED management of pain is also suboptimal
    • Paramedics must participate in research activities and quality improvement initiatives

Medical directors must ensure paramedics have the necessary tools to provide effective analgesia

  •  Agents currently in use in Australia include:

i.     Inhaled:            Methoxyflurane, Entonox

ii.     Parenteral:        Morphine, Fentanyl, Ketamine

iii.     Oral:                 Paracetamol, Ibuprofen, Codeine, Oxycodone

iv.     Intranasal:        Fentanyl, Ketamine

v.     Regional:          Digital blocks, fascia iliaca compartment blocks

Legislative and regulatory barriers to the provision of effective prehospital analgesia must be removed

Research opportunities

  • Effectiveness of routine use of “simple” analgesics for acute pain (e.g. paracetamol) in addition to opiates
  • Effectiveness of oral opiates (e.g. oxycodone) for ambulatory patients in the prehospital setting
  • Strategies to improve paramedic attitudes toward prehospital pain management
  • Role of regional anaesthesia in the prehospital setting

Dr Ed Gentile’s simple, safe, cheap (and fun) approach to management of moderate / severe acute pain for patients < 55 years

Podcast of Dr Gentile’s lecture available at EMCrit at http://emcrit.org/podcasts/gentile-pain/

  1. Administer morphine 0.1 mg/kg i.v.+ diphenhydramine 0.5 mg/kg i.v. (not available in Australia)
  2. 7 minutes later (without any request of the patient) the patient is asked, “Would you like more pain medicine?”
  3. If the answer is yes, the second dose of morphine 0.05 mg/kg i.v. is given
  4. 7 minutes after that (without asking) the patient is offered a third dose and so on….
  5. The protocol repeats until the patient states they have no pain or they don’t want any more pain medicine or the patient is asleep

If 55+ years then Dr Gentile uses 0.05 mg/kg for the initial dose

Advantages of protocol:

  • End point is the patient being completely satisfied
  • Protocol does not discriminate – nor should we
  • Morphine is used as it has the longest half-life of the commonly available opiates
  • Morphine is cheap
  • Seeks to find optimum dose – not the minimum dose

The bottom line

  • Pain is about the patient – after all it is their pain
  • If the patient has pain – give them analgesia
  • The best approach is PATIENT CONTROLLED ANALGESIA…….alternate forms of PCA (paramedic controlled analgesia and physician controlled analgesia) are inferior in the acute setting
  • Little harm will come from sensible analgesic regimes

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