Pain Management (Adult)

 

History:

 

  • Age
  • Location
  • Duration
  • Severity (1-10 or Wong-Baker faces scale)
  • Past medical history
  • Medications
  • Drug allergies

 

Significant Findings:

 

  • Severity (pain scale)
  • Quality (sharp/dull/etc.)
  • Radiation
  • Relation to movement
  • Respiration
  • Increase with palpation of area

 

Differential:

 

  • Musculoskeletal
  • Head trauma
  • Visceral (abdominal)
  • Cardiac
  • Pleural/respiratory
  • Neurogenic
  • Renal (colic)

 

Treatment:

 

  • Oxygen
  • Initiate IV, INT is not acceptable
  • Complete set of vital signs including SAO2
  • Consider Nitrous Oxide

 

  • Consider Toradol 15 mg IV, or 30 mg slow IM; single dose

 

  • Ketamine 0.3 mg/kg IV/IO; 30 mg max single dose; may repeat once after 15 minutes

 

OR

 

  • Morphine 0.1 mg/kg IV/IM up to 5 mg; may repeat once every 5 mins to a max of 10 mg

 

OR

  • Fentanyl 2 mcg/kg slow IV/IO/IM can repeat once in 5 minutes. Max single dose of 100 mcg, Max total dose 200 mcg.

 

  • Must reassess patient at least every 5 minutes after sedative medications.

 

PEARLS:

 

  • Pain severity (0-10) is a vital sign to be recorded pre, and post IV or IM medication delivery, and at disposition.
  • Vital signs whouls be obtained per, 5 minutes post, and at disposition with all pain medications.
  • Zofran (Ondansetron) can cause QT widening.
  • Contraindications to narcotic use:
    • hypotension
    • head injury
    • respiratory distress
    • severe COPD.
  • All patients should have drug allergies documented and avoid medications with a history of an allergy or reaction.
  • Contraindications to Toradol include active bleed (including ulcer and GI) current anticoagulation therapy, pregnant or CVA\TBI < 24 hours, possible surgery.
  • Assess for significant head trauma or GCS less than 13. If present, withhold pain management.
  • Maximize the use of non-pharmaceutical pain management techniques (e.g., positioning, padding and splinting, reassurance, heat/cold therapy, etc.) whenever possible.
  • All patients receiving prehospital narcotic analgesic or benzodiazepines should have continuous pulse oximetry monitoring, EKG, and non- invasive capnography (if available).   All patients who receive IM or IV medications must be observed 15 minutes for drug reaction.
  • Stop Morphine administration if significant adverse effects (severe nausea, vomiting, signs of poor perfusion, respiratory depression) or sedation (decreased mental status) develop.
  • Respiratory depression should be treated with Oxygen and ventilatory support if necessary.
  • Attempt verbal and tactile stimulation to reverse respiratory depression prior to considering Naloxone (Narcan).
  • Administer the smallest possible reversal dose of Naloxone (Narcan) to maintain adequate respirations.