Chapter 67
Analgesia
Richard A. Kamin,
Mark X. Cicero,
Richard A. Kamin
Search for more papers by this authorMark X. Cicero
Search for more papers by this authorRichard A. Kamin,
Mark X. Cicero,
Richard A. Kamin
Search for more papers by this authorMark X. Cicero
Search for more papers by this authorBook Editor(s):David C. Cone MD,
Jane H. Brice MD, MPH,
Theodore R. Delbridge MD, MPH,
J. Brent Myers MD, MPH,
David C. Cone MD
Professor of Emergency Medicine
Yale University School of Medicine, New Haven, Connecticut
Search for more papers by this authorJane H. Brice MD, MPH
Professor of Emergency Medicine
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Search for more papers by this authorTheodore R. Delbridge MD, MPH
Executive Director
Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland
Search for more papers by this authorJ. Brent Myers MD, MPH
Chief Medical Officer ESO Associate Medical Director
Wake County EMS, Raleigh, North Carolina
Search for more papers by this authorFirst published: 18 August 2021
Summary
Treating acute pain and relieving suffering is a primary mission for EMS clinicians. The National Association of EMS Physicians supports every EMS system having a policy to address prehospital pain management. Several studies have shown that insufficient pain treatment is common in prehospital care. Physiological and nonphysiological benefits to prehospital analgesia include improved patient comfort and improved perception of care quality. Although opioids are the most commonly used analgesics, other options include nitrous oxide, ketamine, nonsteroidal anti-inflammatory agents, acetaminophen, and nonpharmacological interventions including therapeutic communication. Many barriers to prehospital analgesia exist, some of which can be addressed through EMS clinician education programs and continuing development of best practice.
References
- McLean SA , Maio RF Domeier RM . The epidemiology of pain in the prehospital setting . Prehosp Emerg Care . 2002 : 6 : 402 – 5 .
- Abdolrazaghnejad A , Banaie M , Tavakoli N , Safdari M , Rajabpour-Sanati A . Pain management in the emergency department: a review article on options and methods . Adv J Emerg Med . 2018 ; 2 : e45 .
- Follin SL , Charland SL . Acute pain management: operative or medical procedures and trauma . Ann Pharmacother . 1997 ; 31 : 1068 – 76 .
- Hewes HA , Dai M , Mann NC , Baca T , Taillac P . Prehospital pain management: disparity by age and race . Prehosp Emerg Care . 2018 ; 22 : 189 – 7 .
- Kennel J , Withers E , Parsons N , Woo H . Racial/ethnic disparities in pain treatment: evidence from Oregon emergency medical services agencies . Med Care . 2019 ; 57 : 924 – 9 .
- Alonso-Serra HM , Wesley K . National Association of EMS Physicians Standards and Clinical Practices Committee. Prehospital pain management . Prehosp Emerg Care . 2003 ; 7 : 482 – 8 .
- Yousefifard M , Askarian-Amiri S , Madani Neishaboori A , Sadeghi M , Saberian P , Baratloo A . Pre-hospital pain management; a systematic review of proposed guidelines . Arch Acad Emerg Med . 2019 ; 7 : e55 .
-
Stewart RD
.
Analgesia in the field
.
Prehosp Disaster Med
.
1989
;
4
:
31
–
5
.
10.1017/S1049023X00038504 Google Scholar
- Dailey M , French D . Sedation and analgesia for the prehospital emergency medical services patient . In: JH Burton , J Miner , eds. Emergency Sedation and Pain Management . New York, NY : Cambridge University Press , 2008 .
- Brewster GS , Herbert ME , Hoffman JR . Medical myth: analgesia should not be given to patients with an acute abdomen because it obscures the diagnosis . West J Med . 2000 ; 172 : 209 – 10 .
- French SC , Chan SB , Ramaker J . Education on prehospital pain management: a follow-up study . West J Emerg Med . 2013 ; 14 : 96 – 102 .
- Lippert SC , Nagdev A , Stone MB , et al. Pain control in disaster settings: a role for ultrasound-guided nerve blocks . Ann Emerg Med . 2013 ; 61 : 690 – 6 .
- White LF , Cooper JD , Chambers RM , Gradisek RD . Prehospital use of analgesia for suspected extremity fractures . Prehosp Emerg Care . 2000 ; 4 : 205 – 8 .
- McEachin CC , McDermott JT , Swor R . Few emergency medical services patients with lower-extremity fractures received prehospital analgesia . Prehosp Emerg Care . 2002 ; 6 : 406 – 10 .
- Hennes H , Kim MK , Pirrallo RG . Prehospital pain management: the comparison of providers’ perceptions and practices . Prehosp Emerg Care . 2005 ; 9 : 32 – 9 .
- Albrecht E , Taffe P , Yersin B , et al. Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study . Br J Anaesth . 2013 ; 110 : 96 – 106 .
- Galinski M , Picco N , Hennequin B , et al. Out-of-hospital emergency medicine in pediatric patients: prevalence and management of pain . Am J Emerg Med . 2011 ; 29 : 1062 – 6 .
- Studnek JR , Fernandez AR , Vandeventer S , Davis S , Garvey L . The association between patients’ perception of their overall quality of care and their perception of pain management in the prehospital setting . Prehosp Emerg Care . 2013 ; 17 : 386 – 91 .
- Abbuhl FB , Reed DB . Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance . Prehosp Emerg Care 2003 ; 7 : 445 – 7 .
- Swor R , McEachin CM , Seguin D , Grall KH . Prehospital pain management in children suffering traumatic injury . Prehosp Emerg Care . 2005 ; 9 : 40 – 3 .
- Evans WO . The undertreatment of pain . Indiana Med . 1988 ; 81 : 848 – 50 .
- Baskett PJ . Acute pain management in the field . Ann Emerg Med . 1999 ; 34 : 784 – 5 .
- Browne LR , Shah MI , Studnek JR , et al. Multicenter evaluation of prehospital opioid pain management in injured children . Prehosp Emerg Care . 2016 ; 20 : 759 – 67 .
- Oberkircher L , Schubert N , Eschbach DA , et al. Prehospital pain and analgesic therapy in elderly patients with hip fractures . Pain Pract . 2016 ; 16 : 545 – 51 .
- Yealy DM , Paris PM , Kaplan RM , et al. The safety of prehospital naloxone administration by paramedics . Ann Emerg Med . 1990 ; 19 : 902 – 5 .
- Pathan H , Williams J . Basic opioid pharmacology: an update . Br J Pain . 2012 ; 6 : 11 – 16 .
- Wedmore IS , Kotwal RS , McManus JG , et al. Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield . J Trauma Acute Care Surg . 2012 ; 73 : S490 – 5 .
- O'Donnell DP , Schafer LC , Stevens AC , et al. Effect of introducing the mucosal atomization device for Fentanyl use in out-of-hospital pediatric trauma patients . Prehosp Disaster Med . 2013 : 28 : 520 – 2 .
- Kanowitz A , Dunn TM , Kanowitz EM , et al. Safety and effectiveness of fentanyl administration for prehospital pain management . Prehosp Emerg Care . 2006 ; 10 : 1 – 7 .
- DeVellis P , Thomas SH , Wedel SK , et al. Prehospital fentanyl analgesia in air-transported pediatric trauma patients . Ped Emerg Care . 1998 ; 14 : 321 – 3 .
- Garrick JF , Kidane S , Pointer JE , et al. Analysis of the paramedic administration of fentanyl . J Opioid Manag . 2011 ; 7 : 229 – 34 .
- Pointer JE , Harlan K . Impact of liberalization of protocols for the use of morphine sulfate in an urban emergency medical services system . Prehosp Emerg Care . 2005 ; 9 : 377 – 81 .
- Bruns BM , Dieckmann R , Shagoury C , et al. Safety of prehospital therapy with morphine sulfate . Am J Emerg Med . 1992 ; 10 : 53 – 7 .
- Miner JR , Burton JH . Pain management . In: R Walls , R Hockberger , M Gausche-Hill , eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 9th ed. St. Louis, MO : Elsevier , 2018 .
- Johnson JC , Atherton GL . Effectiveness of nitrous oxide in rural EMS system . J Emerg Med . 1991 ; 9 : 45 – 53 .
- Ducasse JL , Siksik G , Durand-Bechu M , et al. Nitrous oxide for early analgesia in the emergency setting: a randomized, double-blind multicenter prehospital trial . Acad Emerg Med . 2013 ; 20 : 178 – 84 .
- Faddy SC , Garlick SR . A systematic review of the safety of analgesia with 50% nitrous oxide: can lay responders use analgesic gases in the prehospital setting? Emerg Med J . 2005 ; 22 : 901 – 8 .
- Barrett W , Buxhoeveden M , Dhillon S . Ketamine: a versatile tool for anesthesia and analgesia . Curr Opin Anaesthesiol . 2020 ; 33 : 633 – 8 .
- Green SM , Rothrock SG , Lynch EL , et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases . Ann Emerg Med . 1998 ; 31 : 688 – 97 .
- Green SM , Clem KJ , Rothrock SG . Ketamine safety profile in the developing world—survey of practitioners . Acad Emerg Med . 1996 ; 3 : 598 – 604 .
- Sarma VJ . Use of ketamine in acute severe asthma . Acta Anaesthesiol Scand . 1992 ; 36 : 106 – 7 .
- Jahangir WM , Islam L . Ketamine infusion for post-operative analgesia in asthmatics: a comparison with intermittent meperidine . Anesth Analg . 1993 ; 76 : 45 – 9 .
- Bioin JF . Infusion analgesia for acute war injuries: a comparison of pentazocine and ketamine . Anaesthesia . 1984 ; 39 : 560 – 4 .
- Kakazu C , Lippmann M . Actions and use of ketamine in disaster and trauma patients . ASA Monitor . 2016 ; 80 : 50 .
- Johansson J , Sjoberg J , Nordgren M , et al. Prehospital analgesia using nasal administration of S-ketamine–a case series . Scand J Trauma Resusc Emerg Med . 2013 ; 21 : 38 .
- Graudins A , Meek R , Egerton-Warburton D , et al. The PICHFORK (Pain InCHildren Fentanyl OR Ketamine) trial comparing the efficacy of intranasal ketamine and fentanyl in the relief of moderate to severe pain in children with limb injuries: study protocol for a randomized controlled trial . Trials . 2013 ; 14 : 208 .
- Ahern TL , Herring AA , Stone MB , Frazee BW . Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain . Am J Emerg Med . 2013 ; 31 : 847 – 51 .
- Polomano RC , Buckenmaier CC 3rd , Kwon KH , et al. Effects of low-dose IV ketamine on peripheral and central pain from major limb injuries sustained in combat . Pain Med . 2013 ; 14 : 1088 – 1100 .
- Sobieraj DM , Martinez BK , Miao B , et al. Comparative effectiveness of analgesics to reduce acute pain in the prehospital setting . Prehosp Emerg Care . 2020 ; 24 : 163 – 74 .
- Kiavialaitis GE , Müller S , Braun J , et al. Clinical practice of pre-hospital analgesia: an observational study of 20,978 missions in Switzerland . Am J Emerg Med . 2019 ; 38 : 2318 – 23 . Published ahead of print November 18, 2019.
- Galinski M , Dolveck F , Combes X , et al. Management of severe acute pain in emergency settings: ketamine reduces morphine consumption . Am J Emerg Med . 2007 ; 25 : 385 – 90 .
- Oberholzer N , Kaserer A , Albrecht R , et al. Factors influencing quality of pain management in a physician staffed helicopter emergency medical service . Anesth Analg . 2017 ; 125 : 200 – 9 .
- Goldman G. Biliary colic treatment and acute cholecystitis prevention by prostaglandin inhibitor . Dig Dis Sci 1989 ; 34 : 809 – 11 .
- Masoumi B , Farzaneh B , Ahmadi O , Heidari F . Effect of intravenous morphine and ketorolac on pain control in long bones fractures . Adv Biomed Res . 2017 ; 6 : 91 .
- Khalili G , Janghorbani M , Saryazdi H , Emaminejad A . Effect of preemptive and preventive acetaminophen on postoperative pain score: a randomized, double-blind trial of patients undergoing lower extremity surgery . J Clin Anesth . 2013 ; 25 : 188 – 92 .
- Mahshidfar B , Rezai M , Abbasi S , et al. Intravenous acetaminophen vs. ketorolac in terms of pain management in prehospital emergency services: a randomized clinical trial . Adv J Emerg Med . 2019 ; 3 : e37 .
- Goldfarb B. Prehospital pain management: providing physical and psychological care . Prehosp Care Reports . 1992 ; 2 : 73 – 80 .
- Jacobs DT . Patient communication for first responders and EMS personnel: the first hour of trauma . Englewood Cliffs, NJ : Brady , 1997 .
- Menegazzi JJ , Paris PM , Kersteen CH , Flynn B , Trautman DE . A randomized, controlled trial of the use of music during laceration repair . Ann Emerg Med . 1991 ; 20 : 348 – 50 .
- Ali S , McGrath T , Drendel AL . An evidence-based approach to minimizing acute procedural pain in the emergency department and beyond . Pediatr Emerg Care . 2016 ; 32 : 36 – 42 .
- Luger TJ , Lederer W , Gassner M , Löckinger A , Ulmer H , Lorenz IH . Acute pain is underassessed in out-of-hospital emergencies . Acad Emerg Med 2003 ; 10 : 627 – 32 .
- Walsh B , Cone DC , Meyer EM , Larkin GL . Paramedic attitudes regarding prehospital analgesia . Prehosp Emerg Care 2013 ; 17 : 78 – 87 .
- Murphy A , Barrett M , Cronin J , et al. A qualitative study of the barriers to prehospital management of acute pain in children . Emerg Med J . 2014 ; 31 : 493 – 498 .
- Williams DM , Rindal KE , Cushman JT , Shah MN . Barriers to and enablers for prehospital analgesia for pediatric patients . Prehosp Emerg Care . 2012 ; 16 : 519 – 26 .
- Fullerton-Gleason L , Crandall C , Sklar DP . Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication . Prehosp Emerg Care . 2002 ; 6 : 411 – 6 .
- Bowman WJ , Nesbitt ME , Therien SP . The effects of standardized trauma training on prehospital pain control: have pain medication administration rates increased on the battlefield? J Trauma Acute Care Surg . 2012 ; 73 : S43 – 8 .
