Pain Management- What is your take? Preference? Liberal / Conservative?

[Kiwiology]

Unfortunately Rock Socks in US "opiate or nothing" is the default standard and I have yet to see any service that carries paracetamol, nitrous oxide (owing to the FDA single cylinder ban) or ketamine for analgesia. MCHD in Texas carries ketamine for induction but not analgesia.

In New Zealand we have paracetamol, entonox, methoxyflurane (where carried*), morphine, fentanyl (including intranasal fentanyl), opiate plus midazolam and ketamine (including oral ketamine).

Our indication for pain relief is "pain" without no exception or dosage limits, we can give as much analgesia as is required and professionally prudent to give with the only limit being the physical amount we carry (40mg morphine, 400mg ketamine, 200mcg fentanyl per Officer)

Entonox is fantastic and I've used it pretty liberally, I never finished Upskilling so could only give morphine when supervised but I mean nobody ever disagreed about it, I am aggressive when it comes to treating pain, firmly believe no patient of mine should be left in acute pain and will adequately treat my patients' pain to their satisfaction.

Anybody who does not adequately treat their patients' pain needs to be banned from practising, be cloned, have both their femurs horrendously shattered and angulated, and then be treated by their clone, and any medical director who does not give their paramedics' adequate tools to treat patients' pain needs to be subjected to the same treatment.

* methoxyflurane is carried instead of entonox in space limited situations such as Ambulance Rescue (SERT), Rapid Response Unit and Motorcycle Response Unit vehicles and in very rural stations where re-supply of entonox is problematic.

Carry on.

Edited September 23, 2012 by Kiwiology

[DwayneEMTP]

You know, I hear a lot of excuses from a lot of medics about why they don't choose to mitigate pain, but in my experience it most often comes down to fear. They are just simply afraid to push the drugs and then manage the patient.

On another project that I'm familiar with a man tried to jump out of his vehicle while it was rolling over and ended up with both of his lower legs trapped by the frame at the top of the window. When I asked the medic about the call he said that he thought that "both legs were broken, but not bad.." When I asked about pain management he said, "He didn't need any....he was managing ok." This medic had this patient for 7hrs before he was transfered to a hospital.

I later looked at the medical reports as this patient was going back to his site and saw that he'd had bilat /angulated tib/fib fractures, each fracture requiring plates and pins to repair. Do you think that he was in pain for that 7 hrs? I really, really hate pussy medics.

As far as drug seekers and deciding when a person is in enough pain to be medicated, someone posted some studies that gave strong evidence that non of us is good at calling bullshit on either....

And truly...for most of us...how many drug seekers do you see in a month that catching them should be so high on our priority list?

[Paramagic]

I always find it interesting reading these threads to look at what people consider to be aggressive/appropriate analgesia. People sling around doses like 5mg, or 2mg or whatever. Does no-one else find it curious that pretty much every drug is given on a weight based formula (0.1mg/kg, 3mcg/kg, whatever) yet with morphine we come up with some arbitrary number like 5mg every 5 minutes.

Personally I give 0.1mg/kg morphine as my initial bolus, followed by 0.05mg/kg after that until the pain goes away (or equivalent fentanyl doses). I will obviously change this for certain populations, dropping my initial dose or increasing my subsequent dose, or whatever, but none the less it is always a weight based approach as well.

Ketamine is also, without doubt, the best drug ever, for anything, anywhere.

[chbare]

Ketamine has a rather large side effects profile. Also, it's a direct myocardial depressant. However, those effects are usually negated by the increased sympathetic tone associated with ketamine administration. That is until you administer it to a catecholamine depleted patient...

[Kiwiology]

Ketamine has a rather large side effects profile. Also, it's a direct myocardial depressant. However, those effects are usually negated by the increased sympathetic tone associated with ketamine administration. That is until you administer it to a catecholamine depleted patient...

Ketamine does have side effects yes, most noted are transient tachycardia and hypertension, nystagmus and there are varying reports of frequency and intensity of hallucinations. I personally have never seen hallucinations in the patients I've attended where ketamine has been administered however I acknowledge they are a possibility.

In saying that, ketamine is the worlds bestest analgesic ever where it is not contraindicated

[Paramagic]

The side effect profile of ketamine is no more bothersome than any other analgesia in common use. The most common side effects are easily managed with commonly carried ALS drugs such as benzos or atropine (or glycopyrrolate , but I'm picking not many ambulances stock that)

Knowing the side effects and having had a fair amount of experience with various analgesic options, I still think ketamine is the best drug ever.

[Kiwiology]

The side effect profile of ketamine is no more bothersome than any other analgesia in common use. The most common side effects are easily managed with commonly carried ALS drugs such as benzos or atropine (or glycopyrrolate , but I'm picking not many ambulances stock that)

Knowing the side effects and having had a fair amount of experience with various analgesic options, I still think ketamine is the best drug ever.

I agree, ketamine is quite handy and very effective; I have seen people go from screaming in wretched agony despite appropriate doses of morphine to happily thinking they are a banana and have forgotten all about their pain in two minutes, it can also be used for induction and restraint too, and it is particularly useful in the crook / hypotensive pt as well which makes it even more handy

The only downside is that 200mg/2ml is awfully wasteful I wonder if another concentration is available ....

[chbare]

Unfortunately, there is no best drug ever. It would be myopic to assume a tool can work in every situation. As I've already stated, ketamine has a significant side effect profile and will be associated with significant side effects in certain patients.

Edited September 25, 2012 by chbare

[rock_shoes]

I always find it interesting reading these threads to look at what people consider to be aggressive/appropriate analgesia. People sling around doses like 5mg, or 2mg or whatever. Does no-one else find it curious that pretty much every drug is given on a weight based formula (0.1mg/kg, 3mcg/kg, whatever) yet with morphine we come up with some arbitrary number like 5mg every 5 minutes.

Personally I give 0.1mg/kg morphine as my initial bolus, followed by 0.05mg/kg after that until the pain goes away (or equivalent fentanyl doses). I will obviously change this for certain populations, dropping my initial dose or increasing my subsequent dose, or whatever, but none the less it is always a weight based approach as well.

Ketamine is also, without doubt, the best drug ever, for anything, anywhere.

You make an excellent point. What's interesting is that morphine is the only pain management drug we seem to do that with. Many of us work under protocols where morphine dosing is 0.1mg/kg to a maximum of 5mg for any single dose. Effectively that means you're giving the max dose for everyone over 50kg (ie. only peds really get weight based dosing). My way around it has been to continue with pain control dosing longer in larger patients before switching to more of a maintenance dose.

Sent from my SGH-T989D using Tapatalk 2

[BushyFromOz]

Unfortunately, there is no best drug ever. .

It called beer mate!