Wishful pain control

[Veneficus]

So I was thinking about prehospital pain control. I know different services have various things available. Paying no nevermind to IV opioids as it seems everyone uses those, what do you think would be of most benefit to add to your service and why?

"Pain is a good thing, it lets you know you're still alive"
hot/cold pack
oral nsaids
iv nsaids
hypnotics
nitrous oxide
IM/transdermal opioids
"something michael jackson would have been proud of:" barbiturates, halothane, or propofol

 

[Sasha]

NSAIDs in general. As you have told me before, different kind of pain responds to different kind of meds, and NSAIDs work better on orthopedic pain. I would like to have a non narcotic option for pain control that is not controlled by hot/cold packs.

 

[Shishkabob]

I have Nitronox.

IV Toradol would be nice as it'd give an IV NSAID, plus I hear it works wondors on kidney stones in no way that opiods can.

 

[Meursault]

oral nsaids
iv nsaids
IM/transdermal opioids

Isn't their speed of onset sort of slow for prehospital medicine? I was under the impression that Toradol, for instance, takes upwards of 30 minutes to reach peak plasma concentration when given PO or IM and takes a while to achieve analgesia even when given IV push. You could maybe justify that as starting it before the ED so pain control is achieved earlier and with fewer doses of opioids, but it's not going to do much for patients during your time with them.

/me ducks out of thread before anyone looks at his certification level

 

[MrBrown]

I don't think we need anything more....

Entonox (being withdrawn)
Methoxyflurane
Paracetamol PO
Morphine (being withdrawn)
Fentanyl
Midazolam
Ketamine

 

[JPINFV]

Isn't their speed of onset sort of slow for prehospital medicine? I was under the impression that Toradol, for instance, takes upwards of 30 minutes to reach peak plasma concentration when given PO or IM and takes a while to achieve analgesia even when given IV push.

Time to reach peak isn't nearly as important as time to reach minimum therapeutic concentration.

 

[Smash]

Isn't their speed of onset sort of slow for prehospital medicine? I was under the impression that Toradol, for instance, takes upwards of 30 minutes to reach peak plasma concentration when given PO or IM and takes a while to achieve analgesia even when given IV push. You could maybe justify that as starting it before the ED so pain control is achieved earlier and with fewer doses of opioids, but it's not going to do much for patients during your time with them.

/me ducks out of thread before anyone looks at his certification level

Good question, and your cert level has nothing to do with it. You've already nailed one answer to your question anyway. Aside from some services, aeromedical or otherwise that have a prolonged transport time, use of these agents can povide ongoing analgesia when the patient hits hospital. Not all ER's provide immediate triage, transfer, assessement and treatment, so shorter acting agents may have worn off completely before the patient recieves another bolus.

Other options like IV NSAIDs may also be nice to provide a multifactorial approach to pain management. For example, your patient has a long bone fracture, you start some inhaled agent for immediate pain control, followed by a short acting IV opioid such a fentanyl, and at the same time an IV NSAID. Then during transport morphine may provide longer coverage of opioid while the NSAIDs kick in and do their magic on the ortho injury side of things. Midazolam (Versed) and ketamine could also be thrown into the mix depending on the individual situation.

Pain management is one of the most important aspects of prehospital care and more options are always welcome.

 

[Melclin]

We do analgesia fairly well here. I don't know that we need more drugs, but it would be nice to have a few more options. I do think though that some of the older medics need to get over their apparent fear/aversion to giving them though.

Currently we have:
Methoxyflurane
Morphine
Fentanyl


However,

-I would like the ability to combine midazolam and opiates in certain circumstances, like the kiwis, at least at the MICA level. Our service needs to get over its fear of midaz, and let us use it more appropriately in general.

-I would like to see ketamine on the MICA trucks.

-I would like to have IV fentanyl at the basic level, instead of just IN. Our service needs to get over their fear of the IV route in general.

-I think an IV NSAID would be great - we get a lot of orthopaedic pain, especially with the nannas that fall over, and people (perhaps rightly so) are a bit wary to go with enough fentanyl/morphine/penthrane to make a difference.

 

[Melclin]

Other options like IV NSAIDs may also be nice to provide a multifactorial approach to pain management. For example, your patient has a long bone fracture, you start some inhaled agent for immediate pain control, followed by a short acting IV opioid such a fentanyl, and at the same time an IV NSAID. Then during transport morphine may provide longer coverage of opioid while the NSAIDs kick in and do their magic on the ortho injury side of things. Midazolam (Versed) and ketamine could also be thrown into the mix depending on the individual situation.

Pain management is one of the most important aspects of prehospital care and more options are always welcome.

MMmmmmhhMM Testify!!

 

[MrBrown]

I will admit I know next to nothing about IV NSAIDs

Morphine and midaz combo or morphine and ketamine combo seem to work well on ortho pain here

 

[Smash]

Missed your post MrBrown. That sounds like a good line up of analgesics. I'm curious regarding the rationale for removal of morphine?

 

[Scout]

Why is NZ taking out Entonox?

 

[LondonMedic]

I would suggest that good use of OTC paracetamol and ibuprofen would prevent dozens of A&E attendances in my hossie every day.

 

[Scout]

LM

Do the Brittish Techs or Paramedics have the ability to do that?

 

[MrBrown]

I'm curious regarding the rationale for removal of morphine?

I'm not sure of the "offical" line as it has not appeared in our 2009 Clinical Procedures beyond use for RSI as a pre-induction agent. However it's touted that morphine will be removed and replaced with fentanyl. I immagine it'd be one or more of the following

- Can give fentanyl IN, which is almost totally noninvasive
- Less nausea, vomiting and anaphylactiod side effects
- Passes out of the glomerular filtrate easier
- Synthetic opiod, so its probably cheaper

Why is NZ taking out Entonox?

Other services may continue to use it, but the service I refer to is removing it because methoxy is cheaper and does not require a seperate tank just the little handheld administration device

 

[LondonMedic]

LM

Do the Brittish Techs or Paramedics have the ability to do that?

Do what? Tell people to bugger off? I think that paramedics technically can, but that there's a general unwillingness to do so given the individual risk perceived. There have been plenty of stories, apocryphal or not, of paras being run after the 'sore throat' that they left at home died three weeks later of an MI.

As for the drugs themselves, paras can certainly use them but I don't think many do.

 

[MrBrown]

Do what? Tell people to bugger off? I think that paramedics technically can, but that there's a general unwillingness to do so given the individual risk perceived. There have been plenty of stories, apocryphal or not, of paras being run after the 'sore throat' that they left at home died three weeks later of an MI.

As for the drugs themselves, paras can certainly use them but I don't think many do.

We've been dishing out OTC paracetamol and recommending non transport for at least a few years.

There may be some hesistation around clinical risk of leaving people at home but it's not that wide-spread

 

[LucidResq]

I really wish there was a way to have patients safely self-administer nitrous oxide in the back of the rig.

Safe for the patient, very few adverse effects, great sedative, increases pain threshold, about as fast of onset as you can get, doesn't hang around forever.

I am not a paramedic, but I can imagine it would be excellent to administer in the rig in addition to a low level of IV opiod or some sort of analgesic, so they have immediate relief and that longer-lasting, stronger relief. Then when they're at the hospital the effects of the nitrous will have worn off and the MDs can choose their program for pain relief.

Is it possible to safely administer nitrous oxide with some kind of IV opiod?

 

[JPINFV]

I really wish there was a way to have patients safely self-administer nitrous oxide in the back of the rig.

Are you talking about the patient self administering it or safety from the standpoint of the provider? From the patient's view, my understanding from what I've read online is that it's safely administered because once the patient is unable to hold the mask to their face, then they've reached their maximum dose. The key is not to strap the mask on, just let them hold it.

From the provider safety standpoint, I wonder what the effects would be if a medical air tank was included on board and the provider used a NRB hooked up to the medical air source (alternatively oxygen works well too). It won't completely eliminate the problem, but it would cut down on the amount the provided ended up breathing.

 

[LucidResq]

Absolutely concerned about provider safety. I know that's the reason they took nitrous off the rigs out here several years ago, and it's why the MDs in my OB-GYN clinic don't want to use it even though we have it available. We don't have the right type of ventilation system.

It would be interesting to see how much leak you'd get out of an NRB.

Are you talking about the patient self administering it or safety from the standpoint of the provider? From the patient's view, my understanding from what I've read online is that it's safely administered because once the patient is unable to hold the mask to their face, then they've reached their maximum dose. The key is not to strap the mask on, just let them hold it.

From the provider safety standpoint, I wonder what the effects would be if a medical air tank was included on board and the provider used a NRB hooked up to the medical air source (alternatively oxygen works well too). It won't completely eliminate the problem, but it would cut down on the amount the provided ended up breathing.