Pain management for ems providers

Pain Management for EMS Pain Management for EMS ProvidersProviders

Credit to the following sites:Credit to the following sites:

• American College American College of Emergency of Emergency Physicians is Physicians is credited for the credited for the information information regarding adult regarding adult pain management.pain management.

• http://www.naemsp.org/Documents/http://www.naemsp.org/Documents/CRC%20Handouts-Atlanta/CRC%20Handouts-Atlanta/0041%201.4.3%20Pain0041%201.4.3%20Pain%20Management.pdf%20Management.pdf

• Pediatric Pain Pediatric Pain Management per Management per American Academy American Academy of Pediatrics, use of of Pediatrics, use of article to quote:article to quote:

• PEDIATRICS Volume 130, Number 5, November 2012

• e1397

• FROM THE AMERICAN ACADEMY OF PEDIATRICS

• pediatrics.aappublications.org

Learning Objectives Learning Objectives

• Upon the completion of this program Upon the completion of this program participants will be able to:participants will be able to:

• Describe current state of EMS pain assessment Describe current state of EMS pain assessment and managementand management

• • • Describe most common prehospital uses of Describe most common prehospital uses of analgesiaanalgesia

• • • Describe most common prehospital medicationsDescribe most common prehospital medications

Learning ObjectivesLearning Objectives

• • • Describe barriers to effective analgesia and Describe barriers to effective analgesia and strategies to overcome barriersstrategies to overcome barriers

• • • Describe important differences between adult Describe important differences between adult and pediatric pain managementand pediatric pain management

• • • Describe emerging issues in prehospital pain Describe emerging issues in prehospital pain managementmanagement

Pain IntroductionPain Introduction

• Pain is among most common requests Pain is among most common requests for EMSfor EMS

• • • Pain is associated with increased Pain is associated with increased morbidity and potentially mortalitymorbidity and potentially mortality

• • • Wide variation in EMS assessment and Wide variation in EMS assessment and management of painmanagement of pain

Pain IntroductionPain Introduction

• • • Research shows under treatment / Research shows under treatment / oligoanalgesia is commonoligoanalgesia is common

• • • Significant barriers to more Significant barriers to more effective performance identified in effective performance identified in recurrent studies.recurrent studies.

Conditions for EMS Pain Conditions for EMS Pain ManagementManagement•Most common:

•– Cardiac / Chest, Isolated extremity, Cardiac / Chest, Isolated extremity, BurnsBurns

• • • Less common but growing Less common but growing rationale:rationale:

CA complications, Rheumatoid CA complications, Rheumatoid syndromes, Sickle cellsyndromes, Sickle cell

Conditions for EMS Pain Conditions for EMS Pain ManagementManagement

• Controversial:Controversial:

• – – Trauma extrication, multitrauma Trauma extrication, multitrauma w / wo TBI, nondifferentiated w / wo TBI, nondifferentiated abdominal, Pregnancy/ Labor, abdominal, Pregnancy/ Labor, Patients with pain related condition Patients with pain related condition using other prescribed or using other prescribed or nonprescribed medicationsnonprescribed medications

EMS FormularyEMS Formulary• Non‐pharmacologic management Non‐pharmacologic management

generally needs more attentiongenerally needs more attention

• • • MS remains most common injectableMS remains most common injectable

• • • Fentanyl increasing replacement of MS Fentanyl increasing replacement of MS due to concerns about untoward side due to concerns about untoward side effects.effects.

• • • Other common: Nalbuphine, Meperidine Other common: Nalbuphine, Meperidine (going out) (going out)

• • • Less common: NO/ “Nitronox”, Ketamine, Less common: NO/ “Nitronox”, Ketamine, DilaudadDilaudad

Individual Barriers to Pain Individual Barriers to Pain ManagementManagement• Poor pain assessment skills and reluctance to use inPoor pain assessment skills and reluctance to use in

absence of significant objective signsabsence of significant objective signs

• • • Excessive concerns over “malingerers” and drugExcessive concerns over “malingerers” and drug

seeking behaviorseeking behavior

• • • Unclear endpoints and ambivalence around targetsUnclear endpoints and ambivalence around targets

• • • Fear of masking and aggressive dosingFear of masking and aggressive dosing

• • • Limited education on pediatric and geriatric assessment Limited education on pediatric and geriatric assessment and communication problemsand communication problems

Structural Barriers to Pain Structural Barriers to Pain ManagementManagement• Requirements for direct orders (on‐line)Requirements for direct orders (on‐line)

• • • Dosing regimen’s (initial doses are limited) andDosing regimen’s (initial doses are limited) and

limited total amount carried on EMS unitslimited total amount carried on EMS units

• • • Pediatric assessment support tools, ie. weight based on tapes Pediatric assessment support tools, ie. weight based on tapes and injectables as primary analgesia.and injectables as primary analgesia.

• ••Increased paperwork post call with increasedIncreased paperwork post call with increased

turnaround timesturnaround times

• • • Paramedic education on pain managementParamedic education on pain management

Strategies to Improve Pain Strategies to Improve Pain ManagementManagement• Studies indicate targeted education improves Studies indicate targeted education improves

paramedic confidence and performanceparamedic confidence and performance

• • • Required use of pain assessment and documentationRequired use of pain assessment and documentation

• • • Using standing orders vs. on‐line ordersUsing standing orders vs. on‐line orders

• • • Consideration of other non‐injectables may improve Consideration of other non‐injectables may improve analgesia performance especially for non‐paramedicsanalgesia performance especially for non‐paramedics

““FACES” Pain ScaleFACES” Pain Scale

Emerging IssuesEmerging Issues• Shortages of injectables are affecting EMS and ED medicationShortages of injectables are affecting EMS and ED medication

• AvailabilityAvailability

• • • Unpredictable shortages leading to rapid changes in formularyUnpredictable shortages leading to rapid changes in formulary

• and concentrations.and concentrations.

• • • Changes in formulary and concentrations increase risk ofChanges in formulary and concentrations increase risk of

• medication errors to patients and providersmedication errors to patients and providers

• • • DEA control requirements are further exacerbating shortagesDEA control requirements are further exacerbating shortages

• • • Provider diversionProvider diversion

• • • Unclear use of analgesia agents for pharmacologically assistedUnclear use of analgesia agents for pharmacologically assisted

• airway management and painful extrication.airway management and painful extrication.

Take‐Home PointsTake‐Home Points• Improvements to paramedic education on pain physiology needed toImprovements to paramedic education on pain physiology needed to

improve prehospital pain managementimprove prehospital pain management

• • • Critical populations for improvement are pediatrics, geriatrics, and ethnicCritical populations for improvement are pediatrics, geriatrics, and ethnic

Targeted education and requiring documented pain scoring improve painTargeted education and requiring documented pain scoring improve pain

management performancemanagement performance

• • Changing paramedic education to classes vs. individual medications isChanging paramedic education to classes vs. individual medications is

needed especially due to recurrent shortages and changes in formularyneeded especially due to recurrent shortages and changes in formulary

Improvements needed in non‐pharmacological interventions and potentialImprovements needed in non‐pharmacological interventions and potential

non‐injectable routes of administrationnon‐injectable routes of administration

• • • Standing orders improve performance and time to analgesiaStanding orders improve performance and time to analgesia

• • • Medical Directors need to assess system and practitioner performance.Medical Directors need to assess system and practitioner performance.

• Templates from current studies and NAEMSP Position Papers are useful tools in this effort.Templates from current studies and NAEMSP Position Papers are useful tools in this effort.

• • “• “pain is inevitable, suffering is optional” anonymouspain is inevitable, suffering is optional” anonymous

Credit to :Credit to :

Pediatric Pain Management Pediatric Pain Management per American Academy of per American Academy of PediatricsPediatrics• The learning objectives for pediatrics The learning objectives for pediatrics

are similar to adult pain are similar to adult pain management, with the exception management, with the exception that children often have anxiety of that children often have anxiety of the unknown mixed with the actual the unknown mixed with the actual source of pain. The following slides source of pain. The following slides are sourced from sites noted.are sourced from sites noted.

• It is clear that there is a relationship between anxiety and perceived pain in children and adults.

•The creation of an appropriate environment is essential to minimize the pain and distress of a childs ED visit.

•This is also true of EMS providers, keeping a child’s caregiver’s or a familiar toy or blanket for comfort.

Pain Assessment in the ED

•The Joint Commission standards include mandatory pain assessments for all hospital patients.

•Pain is, by nature, a subjective experienceand is influenced by social, psychological, and experiential factors.

Chronic Pain—all agesChronic Pain—all ages

•For example, patients who experience chronic pain may not report the same pain level or exhibit the same facial cues and vocalizations as those who are new to

the pain experience.

Pain AssessmentPain Assessment

•Pain assessment, which is obviously the

•first step toward appropriate treatment, can, therefore, be more complex than just obtaining a single pain score; it is also essential to pay attention to changes in pain scores in response to treatment.

• PEDIATRICS Volume 130, Number 5, November 2012

Does the Appropriate Use of Analgesics Make Does the Appropriate Use of Analgesics Make Evaluation More Difficult?Evaluation More Difficult?

There is no evidence that pain management masks symptoms or clouds mental status, preventing adequate assessment and diagnosis. For patients with abdominal pain, several adult studies have shown that pain medications such as morphine can be used without affecting diagnostic accuracy.

Pediatric Pain ManagementPediatric Pain Management

•Pediatric studies have demonstrated similar findings.

•Clinical experience suggests that the use of pain medication makes children more comfortable and makes the examination of the patient’s abdomen and diagnostic testing (such as ultrasonography) easier, thus aiding in diagnosis.

•The use of sedative hypnotic medicationmay be required to reduce pain and distress

for children undergoing procedures in the ED.

•Unfortunately, pain and anxiety are often difficult to differentiate in infants and toddlers and even in school-aged children.

•Although many procedures can be performed relatively painlessly with the use of a topical or local anesthetic, this does not obviate the use of pharmacologic agents to decrease the anxiety and stress in children undergoing procedures in the

ED, especially when the child needs to remain still to ensure the success of the

procedure.

•When the procedure is expected to be painful, the agents used should have analgesic properties as well. Emergency physicians are increasingly using short-acting medications such as propofol, alone or in combination with ketamine, for

procedural sedation in children.

Pain Considerations for Children WithDevelopmental Disabilities

•Children with developmental disabilities, particularly those with severe neurologic involvement, provide additional challenges to parents and EMS and ED personnel in management of acute pain and its associated anxiety.

Pain Considerations for Children WithDevelopmental Disabilities

• For many children, previous painful experiences in similar settings add to stress of the acute incident. Learning about the child’s anticipated response and previous experiences from parents, primary care physicians, and specialists informs the emergency physician and staff of useful supportive technique.

Caregiver InvolvementCaregiver Involvement

•Parental understanding and awareness of subtle indirect behaviors or emotional shifts are often critical adjuncts in the assessment process of the child’s sense of comfort and well-being.

CONCLUSIONS

•Management of a child’s distress during illness or after an injury is an important yet complex aspect of emergency medical care for children. Physicians and prehospital EMS providers should be aware of all the available analgesic and sedative options.

•Adequate pain assessment is essential for

pain relief and should begin on entry into the EMS and continue through discharge of the child from the ED.

Implementation•A systematic approach to pain

management in the EMS requires an implementation strategy, promoted and

advocated by leadership, that includesthe following:

• (1) a comprehensive evaluation of current pain and distress management practices;

• ; (2) an educational and credentialing program regarding pain assessment and management techniques for all clinical staff, preferably overseen by a hospital wide sedation committee

;(3)development of protocols to allow the universal and

efficient applicationof pain management strategies and medications; and

(4) a quality improvement process to evaluate the ongoing success of the program.

EMS

•agencies should establish policies and protocols that make available pertinent provider education and ensure quality improvement processes are in place for pediatric pain management protocols appropriate for their practice setting.

SUMMARY OF KEY POINTS

•1. Training and education in pediatric pain assessment and management should be provided to all participants in the EMS for children; EMS medical directors should

• formally include pediatric pain management measures within the protocols provided to EMS providers.

•2. Incorporation of child life specialists

and others trained in nonpharmacologic stress reduction can alleviate the anxiety and perceived pain related to pediatric procedures.

•3. Family presence during painful procedures can be a viable and useful practice in the acute care setting.

•4. Pain assessment for children should begin at admission to EMS, including prehospital management, and continue until discharge from the ED. When discharged, patients should receive detailed instructions regarding analgesic administration

•5. Administration of analgesics and anesthetics should be painless or as pain free as possible.

•6. Neonates and young infants should receive adequate pain prophylaxis for procedures and pain relief as appropriate.

•7. Administration of pain medication has been demonstrated to preserve the ability to assess patients with abdominal pain and should not be withheld.

•8. Sedation or dissociative anesthesia should be provided appropriately for patients undergoing painful or stressful procedures in the ED.

• 9. Pain management and sedation, including deep sedation and dissociative anesthesia, are fully within the monitoring and management capabilities of appropriately trained emergency medicine and pediatric

emergency medicine physicians.

• Each emergency department that provides sedation and analgesia to children should include sedation competencies in recredentialing procedures and develop protocols, policies, and quality improvement programs as part of the systematic approach to pain management in the EMS

PEDIATRICS Volume 130, Number 5, November 2012e1397

•Anxiety relief and pain control using pharmacological agents are critical elements to improving outcome, particularly from the patient's point of view. Careful assessment of the patient and titration of these medications can improve outcomes. In addition to providing pain control, many of the opioids have significant cardiac benefits.

Patient DocumentationPatient Documentation

•The EMS patient record should document any clinical or technical problems during administration of these medications, along with any significant patient events such as nausea and vomiting, respiratory distress, vagal or anaphylactic reaction or diaphoresis, as well as any intervention taken by the paramedic.

Patient MonitoringPatient Monitoring

•Monitoring of patients undergoing sedation and pain control, particularly where the patient is at risk for respiratory, ventilatory, oxygenation or hemodynamic changes from the influence of pharmacological agents, which suppress respiration, is vital to the patient's safety.

•Many such clinical situations occur in settings where standard monitoring equipment is not available or access to the patient and equipment is limited.

•Monitoring should not be limited to intermittent manual observation. Among the noninvasive methods of patient monitoring, several parameters can provide continuous information on the respiratory effort and subsequent ventilation and oxygenation status of the patient.

•The paramedics' ability to use, interpret and act upon the data derived from the patient assessment and monitoring technology will help ensure a positive outcome for the patient. Promoting patient comfort and reducing or eliminating pain are the responsibilities of all prehospital clinicians, while at the same time ensuring patient safety.