3.11. PAIN CONTROL

(The information is based on the instruction on anesthesia in trauma, which is based on the principles of evidence-based medicine).

Related Names

Analgesia, acute pain, acute traumatic pain, acute non-traumatic pain.

Purpose of assistance

Work at the pre-hospital stage requires knowledge and skills in the use of various pharmacological and non-pharmacological means of treating acute pain due to numerous injuries and diseases. The approach to pain relief should be safe and effective in the dynamic conditions of the pre-hospital environment. The level of pain and the hemodynamic status of the patient will determine the need and width of anesthetic manipulations.

Patient description

Inclusion criteria

Patients with existing pain.

Exclusion criteria

1. Pregnancy with active childbirth.
2. Toothache.
3. Patients whose treatment programs prohibit the use of parenteral analgesics by EMF workers.
4. Patients with chronic pain who are not registered in hospices or do not receive palliative care.

Patient Management

Condition assessment, treatment, intervention

1. Determine the patient’s pain level using a standard pain scale:

a) younger than 4 years: FLACC, CHEOPS scales;
b) 4-12 years: Wong-Baker scale, FPS;
c) older than 12 years: NRS Personal Sensation Scale.

2. Connect a heart rate monitor while examining the patient.

3. If possible, use one of the non-pharmacological methods of pain control:

a) positioning the patient in a comfortable position;
b) the use of ice packs and/or splints to control pain that is secondary to injury;
c) verbal calm to avoid panic.

4. If the pain has not decreased and the patient has a significant level of discomfort, use one of the available analgesic drugs (if you have permission from the medical leadership):

a) paracetamol 15 mg/kg orally (maximum dose – 1 g);
b) ibuprofen 10 mg/kg orally, for patients older than 6 months (maximum dose – 800 mg);
c) fentanyl 1 mcg/kg nasally or IV (maximum single dose – 100 mcg);
d) ketorolac (only one dose is allowed for use):

• • • • adults: 30 mg IV (all adult patients except pregnant women);
      • children: (2-16 years) 1 mg/kg w/m (maximum dose – 30 mg);
      • elderly persons: 1 mg/kg w/w (maximum dose – 30 mg);

d) morphine sulfate – 0.1 mg/kg w/m (maximum single dose – 15 mg);
e) ketamine – 0.5 mg/kg nasally (maximum single dose – 25 mg; maximum cumulative dose – 100 mg);
f) nitric oxide

5. Provide IV access and start administering sodium chloride 0.9%.

6. If you have severe or unbearable pain, enter analgesic drugs:

a) ketorolac (only one dose is allowed for use):

adults: 15 mg IV (all adult patients except pregnant women);
children: (2-16 years) 0.5 mg/kg IV (maximum dose – 15 mg);

b) morphine sulfate – 0.1 mg/kg IV or IV (maximum primary dose – 10 mg);
c) fentanyl – 0.1 μg/kg IV or IV (maximum primary dose – 100 μg);
d) hydromorphone – 0.015 mg/kg w/w, w/w or w/c (maximum primary dose – 2 mg; maximum cumulative dose – 4 mg);
d) ketamine – 0.25 mg/kg w/w, w/w or w/c (maximum primary dose – 25 mg; maximum cumulative dose – 100 mg).

7. Use antiemetic drugs (oral, sublingual, IV) to prevent nausea in patients in severe condition (see instruction “Nausea/Vomiting”).

8. If the result on the pain scale is sufficient and vital signs are normal – you can re-enter painkillers (except Ketorolak) 5 minutes after the introduction of the previous dose.

9. Transport in a comfortable position and periodically perform a second inspection.

Nonverbal Pain Scale for Adults (University of Rochester Medical Center)

 

Universal Pain Scale

 

Pediatric Pain Score

FLACC pain rating scale (face – legs – motor activity – crying – sedation).

Age limits of use (according to this instruction) – under 4 years..

 

FLACC Pain Scale Instruction:

1. Conscious patients: Observe them for 1-2 minutes. Watch your legs and torso (they should be uncovered). Change the patient’s position or follow the actions, evaluate the tone and sensitivity of the body. If necessary, calm the patient.
2. Sleep patients: Watch for more than 2 minutes. Watch your legs and torso (they should be uncovered). If possible, change the patient’s position. Touch the patient and assess the sensitivity and tone of the body.

Face

0 points – the face is relaxed, there is eye contact and interest in the environment.

1 point – preoccupation on the face, drooping eyebrows, eyes partially closed, cheeks raised, lips compressed.

2 points – strong wrinkles on the forehead, eyes closed, mouth open with obvious lines around the nose/lips.

Legs

0 points – normal tone and motor activity in the legs and hands.

1 point – increased tone, rigidity, tension, periodic flexion/extension of the limbs.

2 points – hypertonia, leg straightening, excessive flexion/extension of the limbs, tremor.

Motor activity

0 points – calm and free movements, normal activity/limited movements.

1 point – change in position, low motor activity, protective reaction, pressure on certain parts of the body.

2 points – fixed position, head twisting, rubbing of certain parts of the body.

Crying

0 points – no crying/moaning in a conscious or sleepy state.

1 point – periodic moaning, crying, wheezing, sighing.

2 points – the patient needs constant calm or alone can not calm down for a long time.

Subject to reassurance

0 points – the patient is calm and does not need reassurance.

1 point – the patient reacts to calm when touching or talking in ½ to 1 minute.

2 points – the patient needs constant calm or does not calm down for a long time.

At the first best case, the use of behavioral scales for assessing pain is carried out taking into account the subjective sensations of the patient. When a patient is unable to articulate his or her pain, interpreting pain-induced behavior and making decisions about the course of care requires serious consideration of the context in which the behavior manifests itself.

Each category has a score from 0 to 2, the total score varies from 0 to 10.

Behavioral score:

0 = Relaxation and comfort

1-3 = Mild discomfort

4-6 = Moderate pain

7-10 = Severe pain/discomfort

© 2002, Regents of the University of Michigan. All rights reserved.

Source: FLACC: Behavioral Scale for Assessing Postoperative Pain in Young Children, S Merkel et al., 1997, Pediatr Nurse 23 (3), p. 293-297.

Face Pain Scale – Revised (FPS-R).

The chart has been removed for this version of the guideline.

The International Association for Pain Research (IASP) allowed NASEMSO to reproduce the revised Faces Pain Scale (FPS-R) for the PDF web version of the NASEMSO guideline. However, this diagram is removed from this version because NASEMSO does not have permission to allow others to play it. To get permission to play this chart for your guides/protocols, write to: iaspdesk@iasp-pain.org

Patient safety

1. Before the introduction of painkillers, all patients need to determine the presence of allergies to drugs.
2. Be especially careful when administering opioid painkillers to patients on GFR below 15 points, with existing hypotension, existing medical allergies, hypoxia (oxygen saturation below 90%) after oxygen therapy or with signs of hypoventilation.
3. The use of opioid painkillers is prohibited if the patient takes monoamine oxidase inhibitors within the last 14 days.
4. Avoid the use of non-steroidal anti-inflammatory drugs, such as ketorolac in patients allergic to NSAIDs (non-steroidal anti-inflammatory drugs), with hypersensitivity to acetylsalicylic acid, with asthma, renal failure, pregnant women, patients with gastric ulcer.
5. Ketorolac should not be used if renal failure is present (due to renal toxicity).
6. The use of various immobilization techniques and the use of ice packs are designed to reduce the use of painkillers in order to ensure patient comfort.

Useful information for training

Key points

1. Pain (from 0 to 10) should be measured before and after the introduction of painkillers, as well as upon arrival at the admission department.
2. Patients with acute abdominal pain should receive painkillers – the use of analgesics does not mask the clinical causes of pain and does not distort the diagnosis.
3. Opioid drugs can cause an increase in intracranial pressure.

Relevant evaluation results

1. State of consciousness (GCS and pain).
2. Respiratory system (respiratory volume, rigidity of the chest walls).
3. Gastrointestinal system (assess sensitivity, return to normal after pressing, protective reaction, the presence of nausea).

Key elements of documentation

1. Vital signs and pulse oximetry.
2. Detection of allergies before the introduction of drugs.
3. Primary assessment of pain.
4. Administered drugs and correct doses.

Administered drugs and correct doses.

Condition reassessment results (vital signs and pain)