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:

 

• Per the specific protocol
• Musculoskeletal
• Visceral (abdominal)
• Cardiac
• Pleural/respiratory
• Neurogenic

 

Treatment:

 

• Oxygen

• Initiate IV, INT not acceptable

• Full set of vital signs including SAO2

• Consider Nitrous Oxide * Ages > 5 years old only (EMT, AEMT, or Medic)
• Consider Zofran (Ondansetron) 4 mg IV/IO/IM
• Morphine 0.1 mg/kg    IV/IO/IM; max single dose of 5 mg; may repeat once in 5 minutes; Max dose of 10 mg * Ages ≥ 5 years old ONLY.

 

 OR

 

• Toradol 0.5 mg/kg, Max 15 mg IV, 30 mg IM

 

OR

 

• Fentanyl 1 mcg/kg slow IV/IO/IM/IN up to 50 mcg; May repeat once in 5 minutes. Max dose of 100 mcg  * Ages ≥ 5 years old ONLY.

 

• Must reassess patient at least every 5 minutes after sedative medication

 

 

PEARLS:

 

• Pediatric = 1 day to less than age 12, or less than 55 kg in ages 12-18.
• Toradol restricted to patients 2 years of age of older.
• OLMC is required for Morphine, Fentanyl, and Nitrous Oxide for ages < 5 years old.
• Pain severity (0-10) is a vital sign to be recorded pre, and 5 min post, medication delivery, and at disposition with all pain medications.

Age based hypotension:

• • less than 1 year:
    • less than 70 SBP
  • 1-10 years:
    • less than 70 + (2 x age) SBP
  • greater than 11:
    • less than 90 + (2 x age) SBP

 

• Zofran (Ondansetron) can cause QT widening. 8-15 kg: Zofran 2 mg IV/IO/IM, > 15 kg 4 mg IV/IO/IM
• Contraindications to narcotic use include:
  • hypotension
  • head injury
  • respiratory distress
• Contraindictations to Toradol include active bleed (including ulcer and GI) renal disease, possible surgery.
• All patients should have drug allergies documented and avoid medications with a history of an allergy or reaction.
• 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.