A JOINT PRESENTATION I DID WITH ANOTHER TRAINING OFFICER ON PAIN MANAGEMENT

1. Pain Management
ACCESS – CE – 2016 02 Pain Management

2. Objectives
• Understand basic physiology of pain
• Understand the role non-traditional factors play in pain
management
• Understand and avoid biases in pain management
• Assess a patient’s pain
• Understand and apply ACCESS SWO guidelines on
pain management to everyday patient care situations.

3. Developed By
• JD Hendrick EMT-P
• Meridian Fire
Department
• EMS FTO

5. Disclosures
•NONE

6. Resources
• Pain Management for Pre-Hospital professionals-Silver Cross Emergency Medical System
• Prehospital Pain Management Protocols and Ideas-Michael W. Dailey, MD FACEP Regional EMS
Medical Director
• Pain Management 101: From EMS to the ED-Brett S. Greenfield, DO FACOEP/CAQ-EMS;
Medical Director Mid Atlantic MedEvac, Atlanti Care EMS
• Non Traumatic Pain-Steve Cole EMT-P; ACP Training Captain
• ACCESS SWO’s M-11; PM-7
• Pain in Men Wounded in Battle-Lt. Col Henry Beecher, M.C., A.U.S.
• Relevance and Management of Acute Pain in Prehospital Emergency Medicine-Michel Galinski,
MD et. al.
• Position Paper: National Association of EMS Physicians-Prehospital Pain Management- Hector
M. Alonso-Serra, MD et al.

7. Introduction
• According to the International Association for the Study
of Pain: “Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage…”

8. Albert Schweitzer - 1931
• “We all must die. But that I can
save him from days of torture,
that is what I feel as my great
and ever new privilege. Pain is a
more terrible lord of mankind
than even death itself.”

9. Pain Stats
• Trauma is a frequent ED presentation
• 37 million visits annually
• 2.6 million patients are admitted as inpatients annually
• Pain represents more than 50% of the presenting
complaints for ED visits
• In CY 2015: ACP/ACCESS system treated about 11.3 %
of patients with pain medication (2,313 out of 26,197
calls total)
• Morphine: 1209 Patients
• Fentanyl: 1104

10. Pain Serves a Purpose
• It tells us something is wrong with our body that we can’t
see otherwise
• Appendicitis
• Internal bleeding
• It helps us avoid dangerous things
• We touch a hot stove, we feel pain, we pull away
• It helps us protect damaged body parts
• We shield injuries from accidental contact with other people
or things

11. What Causes Pain?
• Pain signals are sent to our
brain by nociceptors (no-si-
sep-tors)
• A nociceptor responds to
damaging stimuli (heat,
pressure, etc.) by sending
nerve signals to the spinal
cord and brain.
• This process, called
nociception (no-si-sep-shun),
is what technically causes
the feeling of pain in
traditional pain mechanisms.

12. The Pain
Pathway
(tutorvista.com)

13. Important fact
• Not all pain is caused by the traditional pain pathway.
• Under the Gate Control theory, dysfunctions in the central
nervous system can mute, or enhance all types of stimuli
as it passes through the spinal chord and parts of the
brain.
• physiological and psychological factors that influence
these “gates”

14. Classifications of Pain
• Acute – sudden in onset, subsides with treatment
• Chronic – persistent or recurrent, hard to treat
• Referred – pain felt somewhere other than its origin
• Heart attack felt in arm
• Spleen rupture felt in shoulder
• Gall bladder felt in shoulder blade

15. Classifications of Pain
Contd.
• Somatic – pain in muscles, ligaments, vessels,
joints
• Superficial – pain in skin, mucous membranes
• Visceral – “deep” pain, hard to localize, arises
from smooth muscles or organ systems

16. Some other kinds of pain
• Neuropathic – caused by damage or disease to the
nervous system
• Tingling, burning, electrical “zapping”
• “Pins and needles”
• Bumping the “funny bone”
• Psychogenic – caused by mental, emotional, or
behavioral factors
• No less hurtful than pain from other sources
• Not “all in their head”

17. A comment on
Psychological Factors
• It has long been known that there are so called
“psychological factors” play a role in the severity of pain.
• Fear, discomfort, anxiety can all aggravate, exacerbate or
enhance pain. The opposite is also true.
• Calming, comforting, and being empathetic has been
shown to help manage pain.

18. What about Phantom
Pain?
• Phantom – felt
after limb is
amputated
• Nerve endings to
stump become
“confused”
• Signal pain to the
brain even though
the limb is no
longer there.

20. Inability to Feel Pain?
• Some people can’t feel pain like they should:
• Diabetic neuropathy
• Spinal cord injury
• Congenital disorders
These conditions may make the patient:
• More prone to injury due to lack of “warning”
• Have a shorter life span due to increased injury risk

21. Who tolerates it better?
• Several studies over the years have shown women
typically display lower pain tolerance than men.
• Unknown whether reason is hormonal, genetic or
psychosocial.
• Researchers suggest men more tolerant of pain because of
“macho” stereotyping, while feminine stereotyping
encourages pain expression

22. Busted!
On the other hand, the show “Mythbusters”
recently found women to be more tolerant of
pain than men, so stereotypical responses may
be changing over time

23. Cultural Differences in Perception of pain

24. How Pain affects our daily lives.
• While pain serves an
important purpose, it
also presents a barrier to
normal functioning
• Pain negatively affects:
• Attention
• Memory
• Mental flexibility
• Problem solving
• Information processing
speed
• Stress levels

25. Pathophysiology
• Pain is more than a just a feeling or sensation, but linked
to the complex psychosocial factors that surround
traumatic events.
• Pain is the brain’s interpretation of the noxious stimulus. •
Nociception
• Derived from the word noxious meaning harmful or
damaging to the tissues.

26. Pathophysiology
• Significant strides have been made as to how the body
senses and interprets pain over the last 2 decades.
• Pain generating pathways more clearly understood.
• Chronic pain better understood.

27. ASSESSING PAIN
ACCESS – CE – 2016 02 Pain Management

28. WHY ASSESS PAIN?

29. Assessing Pain
• The most basic way to characterize pain is the 1-10 scale
(some use 0-10).
• All reports/narratives with patients in pain
should include a 1-10 rating both before, and
after, treatment
• 0 = no pain
• 10= worst pain ever felt

30. Numeric Rating

31. Children Understand Pain different
than adults.
• For children and others with difficulties understanding
the 1-10 scale, you can use the Wong-Baker scale
• Also called the “smiley face” scale
• They point to the picture that best describes their pain.

32. The Wong-Baker Scale

33. Context Matters…

34. What patients think….

35. Assessing Pain - OPQRST
• All narratives for pain and injury should include some
form of OPQRST
• O – Onset (when did pain start)
• P – Palliation/Provocation (what makes it better or worse)
• Q – Quality (what does it feel like)
• R – Radiation (does it move anywhere)
• S – Severity (1-10 scale)
• T – Time (can be combined with O, or can refer to whether it
comes and goes or is steady)

36. Physiological Measurements
• Skin flushing
• Diaphoresis
• Restlessness
• Tachycardia
• Tachypnea
• Elevated BP

37. How do they present/look ?
• What does patient look like?
• Obvious distress?
• Guarding injured limb?
• Yelling?
• Calm and controlled?
• Tense?
• Talking on cell phone?

38. Head-to-toe assessment
• Depending on the mechanism of injury or the nature of
the illness, a head-to-toe exam may be called for too.
• Document all head-to-toe exams. If it’s not written down,
it wasn’t done.
• Don’t let severe pain from one part of the body distract
you from injuries on other parts of the body.

39. Remember DCAP-BTLS

40. Peds. Toe to Head
• Sometime starting at the toes
and working your way up to
the head works better with
kids.
• May be less likely to freak out.
• Kids are the kings and queens
of distracting injuries.
• They don’t understand why a
bloody finger is less important
than a deformed leg.
• Take extra care in examining a
child in pain

41. Key point: Expectation
management with Peds

42. PAIN TREATMENT
ACCESS – CE – 2016 02 Pain Management

43. One of the oldest roles of medical
practitioners is to help alleviate pain.

44. KEY POINT:
• Not everyone needs pain medications, but everyone
should have their pain treated.
• Steve Cole, ACP, OCD

45. Aiming towards zero Pain
• Because pain has as many bad aspects as good, our goal
in EMS is to control pain whenever possible.
• Joint Commission (JCAHO) says pain is 5th vital sign
after BP, pulse, respiratory, and temp.
• The goal – ZERO PAIN!

46. Why Zero Pain?
• It’s humane!
• Pain elicits a strong emotional response that is often recorded
in our memory.
• Cardiac chest pain – Zero pain means less stress on the patient,
lowering pulse and BP, leading to less work for the heart
• Musculoskeletal pain – Zero pain means your patient is more
cooperative, less disruptive and better able to follow directions
• Proper treatment of pain has been shown to decrease incidence
of PTSD in both combat wounded and major trauma victims

47. Still aiming towards zero pain.

48. Sometimes zero pain is not the goal.
• There are a few times in EMS when we don’t want to
treat pain
• Headache – pain medication can mask symptoms of a more
serious head injury
• Drug-seeking patient
• Consult medical control if there is a concern
• Consult their pain contract/plan
• Remember, these patient’s can have painful issues too!
• Always err on the side of the patient’s best interest.
• Hemodynamically unstable patient’s

49. Why are we not treating pain?
Possible factors:
• Biases and prejudices?
• Poor patients,
• Patients we think are faking it, patients who are
“whiners”
• Gender?
• Fear of medication administration?
• Giving narcotics is a big responsibility, especially
if we are not comfortable with our skills and math
ability

50. Could it be “our” issues?

51. Other options as to why we under treat
• Oligoanalgesia: undertreatment of pain
• Why is pain under treated?
• Failure to assess
• Failure to quantify
• Fear of ‘masking’ pain
• Fear of side effects & addiction
• Legal constraints of utilizing controlled substances
• Lack of training & experience

52. Michel Galinski, MD et. Al. Concluded…
• “In our studied population…pain in prehospital
emergency medicine affects 42% of patients…Pain
management is inadequate, as only one in two patients
experience relief.”
Galinski, M., Ruscev, M., Gonzalez, G., Kavas, J., Ameur, L., Biens, D., . . . Adnet, F. (2010).
Prevalence and Management of Acute Pain in Prehospital Emergency Medicine. Prehospital
Emergency Care Prehosp Emerg Care, 14(3), 334-339. Retrieved from
http://www.naemsp.org/Documents/Topic004-Galinkski-
PrevalanceEffectivenessPrehospPainMgmnt-PEC-2010.pdf

53. GENDER BIAS IN PAIN
MANAGEMENT
• American Journal of Emergency Medicine, Oct 2007…
“women are less likely than men to receive prehospital
analgesia for isolated extremity injuries… Increasing levels of
income were associated with increased rates of analgesia.”

54. Pain Management
• Pain medications/treatments address two components of
pain:
• The actual sensation of pain
• The emotional response to pain
• We carry medications and treatments on the ambulance
that address both components
• Don’t forget BLS treatments… often just as effective
as ALS medications, and easier too.

55. BLS PAIN MANAGEMENT
ACCESS – CE – 2016 02 Pain Management

56. BLS-Cold Packs
• Cold packs often a forgotten element of
pain management.
• Reduce swelling and pain in strains,
sprains and fractures.
• When possible, do not put directly on
injured area.
– Can cause tissue damage
– Wrap in pillow case or gauze first

57. Why do cold packs work?

58. Splinting

60. Pain has a psychological and
a social-situational aspect
• “There is a common belief that wounds are
inevitably associated with pain, and, further,
that the more extensive the wound the worse the
pain. Observation of freshly wounded men in
the combat zone showed this generalization to
be misleading…..”

61. A point to ponder
• Pain that arises from a psychological/social origin is no
less real to the patient than one arising from a physical
injury. Only the effective therapies may be different.

62. Other street wise tips…

63. ALS PAIN MANAGEMENT
ACCESS – CE – 2016 02 Pain Management

64. What is in the Narc. Box?
• Fentanyl
• Morphine
• Nitrous Oxide (Not in
protocols)
• Ketamine (Not in protocols)
• Provider
• Administered
• Intravenous
• Narcotics

65. Opiates
• Three opioids we
need to know:
• Morphine
• Fentanyl
• Dilaudid
• Bind with opioid
receptors in the brain
– Alters perception
of pain
– Alters emotional
response to
painful stimulus

66. Opioids - Introduction
• Commonly carried by EMS
• Chief alkaloid of opium
• Carried by prehospital crews because
– It’s cheap
– It’s been around a long time
– It works without too much fuss
– It’s easy to treat if we give too much of it
(Narcan)

67. Opioids- MOI
• The opioid system had 4 different types of receptors: μ,
Delta, Kappa and Sigma receptors.
• Most EMS opioids effect “μ” (“mu”) receptors, and a
collection of others.
• There are 3 different μ receptors: They largely provide for
CNS depression, and analgesia.
• The other receptors have wide variety of functions,
including some “overlap” with μ receptors.

68. Opioids- Side Effects
• Respiratory depression
• Nausea/vomiting
• Constipation
• CNS depression
• Careful administration can prevent many of these side-
effects

69. Morphine: M-11

70. Morphine: M-11

71. Morphine- PEDIATRIC DOSES?

72. Morphine and Peds: PM-7

73. Morphine and Allergies
• Don’t give if allergic to morphine….duh!
• Use Dilaudid or Fentanyl instead
• Be aware: Morphine (and other opioids) can cause a small
histamine release in patients. This is not normally
considered an allergy.
• Itchy nose: This is not normally considered an allergy.
• Allergy to sulfa drugs not a contra-indication to Morphine
Sulfate administration
• Sulfa and Sulfate are not the same thing (not even close!)

74. Fentanyl: M-11
A truly synthetic opioid agonist
Many benefits over other opioids
50-100 x more potent than Morphine
Lipophilic allowing rapid penetration of the BBB
Rarely causes allergic response
But…not as euphoric 

75. Fentanyl-Indications: M-11

76. Fentanyl-Dose: M-11

77. Fentanyl-Indications: M-11

78. Fentanyl-Don’t forget IN route:
Appendix 21

79. Fentanyl vs. Morphine
• Duration:
• Fentanyl is shorter acting
• Route
• Fentanyl may be given IN
• Euphoria
• Morphine may produce stronger euphoria
in addition to pain control

80. Dilaudid?

81. Dilaudid

82. What about
Hemodynamics?

83. A comment on Opioids
and RSI/MAI

84. What about
Benzodiazepines/Sedatives?
• ACCESS/ACP does not use benzodiazepines/sedatives
for analgesia.
• Doing so increases the risk of respiratory depression and
hypotension
• EXCEPTION: Versed may be used as sedation prior to
certain painful procedures, such as pacing or cardioversion
(ACCESS SWO’s)

85. Anti-Emetics
Antiemetics:
• Zofran (Ondansetron) IV/IM/IO 4 mg: Repeat one time in 15 minutes, if
needed
• Benadryl (diphenhydramine) IV/IM/IO: 25-50 mg

86. Anti-Emetics
Antiemetics:
• Zofran (Ondansetron) IV/IM/IO 4 mg: Repeat one time in 15 minutes, if
needed
• Benadryl (diphenhydramine) IV/IM/IO: 25-50 mg

87. WHERE TO FIND THE
PROTOCOLS
ACCESS – CE – 2016 02 Pain Management

89. www.adaparamedics.org

90. Finding our SWO’s

94. ACCESS SWO’s are
available on your smart
phone.

95. And in hard copy…

96. SPECIFIC PAINFUL SITUATIONS
ACCESS – CE – 2016 02 Pain Management

97. Chest Pain
• Initial treatment does include aspirin
• But not for pain, for better cardiac outcome
• While still hotly debated, the AHA still recommends :
• “Morphine is indicated in STEMI when chest
discomfort is unresponsive to nitrates (Class I, LOE
C).”

99. What about Abdominal
Pain?

100. “….Therefore medication of abdominal pain is both
humane and appropriate medical care.”
- ACCESS SWO’s
• Regarding Abdominal Pain: Narcotic analgesia was historically considered
contraindicated in the pre-hospital setting for abdominal pain of unknown
etiology. It was thought that analgesia would hinder the ER physician or
surgeon's evaluation of abdominal pain. It is now becoming widely recognized
that severe pain actually confounds physical assessment of the abdomen and that
narcotic analgesia rarely diminishes all of the pain related to the abdominal
pathology.
• It would seem to be both prudent and humane to "take the edge off of the pain"
in this situation with the goal of reducing, not necessarily eliminating the
discomfort. Additionally, in the practice of modern medicine the exact diagnosis
of the etiology of abdominal pain is rarely made on physical examination.
• Advancement in technology and availability has made laboratory, x-ray,
ultrasound, CT scan, & occasionally MRI essential in the diagnosis of abdominal
pain.
• Therefore medication of abdominal pain is both humane and appropriate
medical care.

101. Isolated Extremity Injury
• First control bleeding with direct pressure and elevation.
• Splint fractures, sprains and strains
• BLS – a cold pack can reduce swelling and pain
• ALS – Opioids
• No opioids if hypotensive
• Defined as < 90 mm Hg systolic
• (or based on age if pediatric).

102. Extremity Injuries:
Consider the context

103. Back Pain
• Though the yearly
prevalence is stable at 15%
to 20%, nearly 80% of adults
will experience back pain at
some point during their
lifetime, with 31% of
patients annually requiring
time off from work
• Varies from acute, to
chronic, and acute
exacerbation of chronic pain

104. Back Pain contd.
• Muscle strain and spasm
• Lumbar
• Diffuse right and/or left
• Palpable tetany of
muscles
• Classic Presentation:
Doesn’t want to move…
• Sciatica
• “Sciatic Pattern”
• May or may not be
associated with muscle
spasms

105. Sciatic Pattern

106. What about the
intoxicated?

107. EMS and Chronic Pain
Patients
• No, I am not talking about us. Though all
of us have it.
• I am talking about our patients.

108. EMS and Chronic Pain
Patients
• Defined as pain that lasts longer than six months.
• Can be mild or excruciating, episodic or continuous,
inconvenient or incapacitating.
• May originate with an initial trauma/injury or infection,
or an ongoing medical cause.
• Or can have no cause at all
• No past injury or illness

109. EMS and Chronic Pain
Patients
• Higher rates of depression and anxiety.
• Sleep disturbance and insomnia common.
• Substance abuse highly prevalent in chronic pain
population.
• Chronic pain may contribute to decreased physical
activity.
• Fear of making pain worse.

110. What is a Pain Contract?

111. EMS and Chronic Pain Patients
• Arthritis
• Back Pain
• Cancer
• Chronic Fatigue Syndrome
• Clinical depression
• Fibromyalgia
• Headache
• Irritable Bowel Syndrome
• Sciatica
• Lumbar spinal stenosis and cervical spinal stenosis

112. Treatments for Chronic Pain
From National Institute of Neurological Disorders and Stroke
• Medications
• Acupuncture
• Local electrical
stimulation
• Surgery
• Placebos
• Psychotherapy
• Relaxation
• Biofeedback

113. EMS and Chronic Pain
• Patients with chronic pain call EMS for many reasons
• Pain recently got worse
• Pain recently changed or moved
• Pain now accompanied by new swelling, heat or deformity
• Patient hopes EMS can provide pain medications that MD
cannot or will not
• Pain impinges on an Activity of Daily Living ADL

114. Chronic Pain: Ponder This
• The EMS provider should remember that chronic pain is
still a medical disorder
• Not all in their head
• Not all patients with chronic pain are drug-seekers
• Not all patients with chronic pain are “whiners”
• Do not make light of their condition

115. Drug Seekers?

117. Summary
• Because pain has as many bad aspects as good, our goal
in EMS is to control pain whenever possible.
• Joint Commission (JCAHO) says pain is 5th vital sign
after BP, pulse, respiratory, and temp.
• The goal – ZERO PAIN!
• Don’t be afraid to use the tools we have to achieve that
goal.