Pain Management, Multi-Systems Trauma

[croaker260]

Our protocols not only allow medication of abd. pain, it encourages it.

From our protocols, I quote:

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.

[Paramagic]

Really?

Yes, really. What kind of patient benefits from being in pain?

[DwayneEMTP]

Yes, really. What kind of patient benefits from being in pain?

70 y/o F, normally bedridden, open book pelvic fracture from fall. Initial B/P 78/44, altered, screaming in pain. History of dementia/COPD/CHF, course crackles to lower lobes bilat.

30 y/o F, c/c of "my head is splitting apart! If feels just like the last time I had a stroke!" PERRL, all physiological markers acceptable for situation. The problem was, according to her parents she had had several strokes in the past two years, each leaving a deficit, and in this case her behavior screamed of bullshit to me. But I had nothing but her behavior, speech patterns/diction/facial movement/extremity movement etc to monitor her current status and track it during transport. I chose not to medicate based on the fact that I was unable to establish a reasonable baseline and couldn't risk losing my markers under the narcs.

These patients suffered short term but I believe benefited long term. Of course my goal is to always manage both. But forced to choose, I have to choose 'life over limb' and attempt to mitigate long term morbidity even at the expense of short term suffering. Or at least that is my belief.

I was in no way questioning the spirit of your comment Brother, as I love the spirit. What I was questioning was the reliability of the 'absolute' statement. I've found nothing in life, and particularly EMS to be absolute.

Dwayne

[Paramagic]

70 y/o F, normally bedridden, open book pelvic fracture from fall. Initial B/P 78/44, altered, screaming in pain. History of dementia/COPD/CHF, course crackles to lower lobes bilat.

30 y/o F, c/c of "my head is splitting apart! If feels just like the last time I had a stroke!" PERRL, all physiological markers acceptable for situation. The problem was, according to her parents she had had several strokes in the past two years, each leaving a deficit, and in this case her behavior screamed of bullshit to me. But I had nothing but her behavior, speech patterns/diction/facial movement/extremity movement etc to monitor her current status and track it during transport. I chose not to medicate based on the fact that I was unable to establish a reasonable baseline and couldn't risk losing my markers under the narcs.

These patients suffered short term but I believe benefited long term. Of course my goal is to always manage both. But forced to choose, I have to choose 'life over limb' and attempt to mitigate long term morbidity even at the expense of short term suffering. Or at least that is my belief.

I was in no way questioning the spirit of your comment Brother, as I love the spirit. What I was questioning was the reliability of the 'absolute' statement. I've found nothing in life, and particularly EMS to be absolute.

Dwayne

I don't really see the benefit in having unrelieved pain in either of those patients. In the first vignette I presume that the concern is the low BP? In which case some ketamine, or small aliquots of fentanyl would be appropriate.

In the second scenario there is no reason for pain not to be treated either. The concern over 'masking' neurological signs by sedating the patient just means that you don't use large doses of a sedating analgesic. Fentanyl again is a good option due to it's short duration of action which will allow unhindered neurological examination when the neuro people see her (although lets face it, she will be getting a CT and CTA, possibly an MRI also, so it;s a bit like the abdominal pain myth) Or you could use NSAIDs, or some inhaled analgesia.

[DwayneEMTP]

...or small aliquots of fentanyl would be appropriate...

Yeah, you could be right, but I've never been a fan of small doses of any type of pain management, and in fact believe that in doses small enough not to mask physiological markers often removes their natural ability to mentally manage the pain and seems to make it worse. I've no experience with Ketamine though.

I believe that my experience with dealing with pain is not insignificant, yet find that if I lead a patient with significant pain into analgesia/sedation inch by inch it often seems to kill their faith in it and it takes much more to manage them than those that I started off with a good shove.

I'd be curious of the opinions of others, but I believe low doses often to be worse than nothing. Of course because of this I have rarely used it. 25mcgs Fent in an 'average' sized patient? Yeah, more likely to make things worse instead of better in my experience.

Dwayne

[Bieber]

Dwayne, my understanding is that the hypotension associated with fentanyl is minor at best and arguably a complete non-issue. Furthermore, reducing pain (primarily but not solely in abdominal pain patients) can actually have an increase in blood pressure because the patient will no longer be tensed up and overstimulating their vagus nerve.

As for the second patient, I have never heard of a stroke being a contraindication for pain management, but I would think that decreasing pain would facilitate a proper neurological assessment; the only concern being the risk of dropping their blood pressure (and thus their cerebral perfusion pressure) if it's a hemorrhagic stroke which, with fentanyl, shouldn't be an issue.

[DwayneEMTP]

On the first patient how minor of a depression would you consider acceptable? Even had her pit bull eaten my B/P cuff, I'm confident from her altered mentation, pulse quality, (What I know it must have been. Not pretending to remember now) that perfusion pressure is already critical, how much more critical is acceptable in order to manage her pain? What will you do to correct the current issues as well as overcome the minor depression?

Ok, to both of you, do me this favor. And this is in the spirit of learning not a "So you think so, do you!!" moment. You've convinced me that I 'may' be off in the ditch on this issue. I'm hoping you can convince me that I am...

Define the first patients injuries, her presentation and history and then your treatment to include all interventions, drugs, dosages. This will assume, as in reality, a 15 minute transport time to a level 3 trauma center.

And for the record, I didn't know exactly what the injury was when I treated her. I followed up on her at the ER and was informed there. Only that she was altered, seemed in terrible pain from an undiagnosed pelvic injury after falling from her bed, and that I was confident by her physiological markers that she was losing, if not into her pelvic cavity as I believed, a bunch of blood somewhere internally.

I didn't medicate her pain, and still feel that that was the prudent decision, but I'm miles away from knowing even what I'd like to, much less knowing everything...give 'er hell!

Dwayne

[Bieber]

Dwayne, was the first patient acting normal and appropriate compared to her baseline or was she altered from her normal status? I think as far as fentanyl in the setting of an already hypotensive patient it comes down to a judgment call. You said her perfusion status was critical? What was the rest of her presentation with regards to her end-organ perfusion (besides the altered mental status, assuming it was altered from her baseline)? As far as treatment, if I had no clue she had a pelvic fracture, I'd try to localize the source of her pain/distress, which if she was too distressed to state because of the pain might be facilitated by carefully titrating fentanyl until she was at a level of comfort that she could give you some clue as to what was going on.

If she's got the crackles, fluid might exacerbate that especially if her heart isn't keeping pace (which if she's got fluid in her lungs, it isn't), and unfortunately hypotension is a contraindication for CPAP. Let me get a full history and vitals from you and I can tell you more of what I would do, but to start us off why don't we:

-Sit her up if she tolerates it. It might drop her pressure but we can't give fluid if all it'll do is fill her lungs up, and we don't want to go the dopamine route until we have a better history so we're not giving it in the presence of incomplete fluid replacement.

-Get her on an NRB at 15 LPM and see if we can get some of that fluid out of her lungs so we can deal with her circulatory problem.

-Get a line in place with NS TKO for the time being and do a 12-lead EKG.

-Get a full history of present illness, along with any other medical history not already noted along with meds and allergies!

Also, an open book pelvic fracture occurs at the symphyses pubic and at one or both of the sacroiliac joints, usually from injuries to the groin. Gonna need surgery. And the patient's presentation (assuming she is altered from her baseline) is consistent with end-organ hypoperfusion.

Addendum: I'm going at this scenario from the presumption that we don't know that this patient has a pelvic fracture at the moment.

[PCP]

What if you are a BLS car and all you can administer for pain is Entonox?

Would I be wrong to attempt to have dispatch page out the ALS crew to come and administer pain medication if I felt that my patient would benefit from stronger pain medication which I don't carry on car?

The town I work and live in we can be at the hospital within 10-20 code 3. Would it benefit my patient or just delay transport time if I paged out ALS to administer pain meds.?

[Vorenus]

I love toradol for stones also. Like I said, the urologists won't touch a pt that has had it so they are getting a longer hospital stay. I won't go into the details but they got successfully sued after a pt died during a procedure that received toradol. It was a BS suit but this is America so sometimes you get your winning lottery ticket.

What about Buscopan (butylscopolamin)? Didn`t read it in that context anywhere.

.

-Get her on an NRB at 15 LPM and see if we can get some of that fluid out of her lungs so we can deal with her circulatory problem.

How is that going to improve her possible lung edema? Or did you mean CPAP?