Pain Management

A pain assessment is considered standard of care on every patient, along with an initial set of vitals, and should be documented on the run report along with any pain management intervention and the patient’s response.

 

BLS

 

Attempt to place patient in position of greatest comfort

 

For Mild Pain, EMTs can consider the following:

 

  1. Acetaminophen may be administered to patients > 15 years old and > 50 kg as 650 mg PO once
    1. Unless the patient has:
      1. An allergy to acetaminophen
      2. A history of liver dysfunction
      3. Active vomiting
      4. Acetaminophen use within last 4 hours
  2. Acetaminophen may be administered to patients older than 6 months and is able to take PO, administer 10mg/kg PO acetaminophen (max dose 650mg).
    1. Unless the patient has:
      1. An allergy to acetaminophen
      2. A history of liver dysfunction
      3. Active vomiting
      4. Acetaminophen use within last 4 hours
ALS

 

Paramedics should consider offering pain medication to any patient describing pain. Medications should be selected by paramedic judgment of pain severity (mild, moderate, severe) and is not necessarily limited to single pharmacologic agent.

 

Mild Pain
  1. Paramedics should consider offering patients describing mild pain acetaminophen for pain management.
  2.  

    1. Acetaminophen may be administered to patients > 15 years old and > 50 kg as 650 mg PO once
    2.  

      1. Unless the patient has:
      2.  

        1. An allergy to acetaminophen
        2. A history of liver dysfunction
        3. Active vomiting
        4. Acetaminophen use within last 4 hours

       

    3. Acetaminophen may be administered to patients older than 6 months and is able to take PO, administer 10mg/kg PO acetaminophen (max dose 650mg).
    4.  

      1. Unless the patient has:
      2.  

        1. An allergy to acetaminophen
        2. A history of liver dysfunction
        3. Active vomiting
        4. Acetaminophen use within last 4 hours

     

    Moderate Pain

     

  3. Paramedics should consider offering patients describing moderate to severe pain ketorolac (Toradol®) for pain management.
  4.  

    1. Ketorolac is administered in the following doses:
      For patients > 15 years old: 15 mg IV or 30 mg IM once.
    2.  

      1. Unless the patient has:
      2.  

        1. An allergy to ketorolac, aspirin, or other NSAIDS
        2. History of renal dysfunction
        3. History of GI bleed
        4. Active bleed or suspicion of active bleed
        5. NSAID use within last 6 hours
        6. Pregnancy

     

    Severe Pain

     

  5. Paramedics should consider offering patients describing severe pain fentanyl for pain management.
  6.  

    1. Fentanyl is administered in the following doses:
    2.  

        Patients > 15 years old and > 50 kg:

         

          Up to 100 mcg slow IV push or intra-nasal. Up to an additional 50 mcg may be administered every 5 minutes up to a maximum of 300 mcg prn pain > 3/10. Consider lower doses for patients > 65y/o or those with other comorbid conditions.

       

        Patients < 15 or < 50 kg:

         

          Up to 1mcg/kg slow IVP or 1-2 mcg/kg intra-nasal, can be repeated two more times every 5 minutes prn evidence of significant discomfort.

           

          1. Unless the patient has:
          2.  

            1. An allergy to fentanyl; OR
            2. A significantly altered level of consciousness (GCS < 14 or below baseline)

             

          3. Additional doses may be administered with approval of Medical Control.
          4.  

  7. Naloxone must be immediately available.
  8.  

    Breakthrough Pain

     

  9. After one dose of fentanyl, paramedics can consider augmenting pain control with intranasal ketamine if pain remains severe. Fentanyl using the Severe Pain protocol can still be administered after ketamine use.
  10. Source of pain must be due to serious traumatic injury, which includes, but is not limited to: extensive burns, open fractures, skeletal deformities, limb entrapment or amputation
  11.  

    1. Adults Patients Only (15 years and older): Intranasal ketamine is administered in the following dose
      0.5 mg/kg intranasal, max 50mg. This is a one time dose only.

     

    Patient's BP, HR, RR, GCS, and pain scale must be monitored regularly (at least once prior to and once after the dose(s) of medication) and documented on the patient care record. ETCO2 capnography must be applied if intranasal ketamine is used.