Pain relief and EMS

[WelshMedic]

The abdo pain example reminded me of something I heard recently while listening to the podcast of the Merck Manual of Patient Symptoms on Abdominal pain. (not the most scholarly source, nor particularly easy to reference I know) In it, their speaker a Dr. Robert Porter (whose credentials on the Merck site are listed as "Clinical Assistant Professor, Department of Emergency

Medicine, Jefferson Medical College") states that (paraphrased):

While it was once thought that pain medication would mask abdominal signs, and some clinicians may still feel this way, that it seems clear that moderate doses of IV analgesic (50-100mcg fentanyl or 4-6mg Morphine) do not hide paretineal signs. In fact the decreased anxiety and discomfort in the patient may make examination easier.

I listened to this section of the podcast again just to be sure since I can't post the exact source. Anyone have anything more credible to back this up or even protocols that allow for pain meds in cases of abdominal pain?

Denying pain medication to a pt. with abdominal pain is something still from the dark ages. There is a plethora of studies that disprove this opinion. Not even mentioning the fact that, with today's medical imaging capabilities, it makes no sense whatsoever.

If your pt. is in pain, then they deserve pain relief.

WM

[Novisen]

Sounds midevil. No pain medication for abdominal pain?

Patients with collum fractures we give pain mediciations (Ketobemidon or Morfin and 2g Paracetamol), start an Glucos dripp, give oxygen. When we arrive to the hospital we take blood tests, change clothes and take the patient to x-ray. After that we leave the patient in the ortopedic section. Only if we get a new job the ER takes over the patient.

[Novisen]

Watch this guy gets painrelief with Ketamine! The sounds he makes is common after having Ketamine. He also gets 10mg Diazepam and 2 mg Midazolam

http://www.youtube.com/watch?v=ugp6898rT5Y

[croaker260]

Anyone have anything more credible to back this up or even protocols that allow for pain meds in cases of abdominal pain?

I recall an old study published in the Annals of Emergency Medicine about 1995 ish discussing this topic. It was a huge study in Asia somewhere, and found that pain meds made the Dx of appendicitis easier for "blinded" surgical residents.

Anyway, here are our protocols for pain meds....

In our service our supply told us that the only drug we give more of (than morphine) is albuterol. We commonly will co-administer a benzo for spasms or sedation as well.

All of our narcotics are considered standing orders (except etomidate, unless its used for RSI/MAI- Different protocol though) .

http://www.adaweb.net/LinkClick.aspx?filet...d&tabid=798

I qoute from page 2:

Regarding Abdominal Pain: Narcotic analgesia was historically considered

contraindicated in the prehospital 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.

Edited May 3, 2009 by croaker260

[hertzvanrental]

In the UK we have the following options:

Paracetamol

Ibuprofen

The above can be given together or independently

Entonox

Tramadol (depends where you work)

Nalbuphine (now withdrawn I believe)

Morphine up to 20mg for adults , paeds are age/weight related.

Oramorph (oral morphine)

Ketamine/midazolam (flight paramedics and CCPs)

There is also talk of intranasal diamorph in the future.

I'd like to see Fentanyl added personally.

Decent analgesia is underused and for what reason? There is no justifable reason to withold proper analgesia.

I know it only shows a very minute proprotion of paramedics but the US Paramedic reality shows I've seen rarely show any medics giving pain meds.

Pain is something we can treat and a lot of our patients are in pain so we should be treating them.

As for the abdo pain BS, any decent DR worth their salt should be able to daignose the problem irrespective of prehospital analgesia.

Also forgot to mention Lidocaine with EZ-IO, also Lido for suturing for Paramedic practitioners and ECPs.

[spenac]

I think doctors and Paramedics that with hold pain meds for no scientifically sound reason should be made to suffer. Then they would be quicker to consider patients comfort.

[mobey]

I think the thought process behind the idea of witholding pain relief from abd pain comes from before endoscopy, CT scanners, ultrasound and MRI's.... |Really.... the patient could have no complaint and they could still find a problem with the above tools.

[WolfmanHarris]

I think doctors and Paramedics that with hold pain meds for no scientifically sound reason should be made to suffer. Then they would be quicker to consider patients comfort.

The story goes that in Toronto a few years ago, Dr. Mazza one of the Sunnybrook-Osler Medical Directors fell off his roof. When TEMS Paramedics responded to him and gave MS he asked for more. They told him that their protocol, written by him, didn't allow them more and that as he was the patient, he couldn't be OLMC. At the next CME, maximum doses for pain meds were increased. Coincidence?

[HarryM]

I'm a BLS and have the following options:

• Entonox
  
• Paracetamol
  
• Methoxyflurane
  

In our service ILS gets morphine and ALS gets ketamine and midazolam added onto that.

[Dustdevil]

Watch this guy gets painrelief with Ketamine! The sounds he makes is common after having Ketamine.

Do you mean the high-pitched whine he lets out at 2:42 and again at 3:57?

He didn't get the Ketamine for pain relief. You have to gork motorcyclists before they will allow you to cut their leather!

Cool vid! Certainly quite definitive of the term "luxation"!

Edited May 29, 2009 by Dustdevil