PAIN MANAGEMENT GUIDELINES
ALL LEVELS
Routine Patient Care. Consider all patients as candidates for pain control regardless of transport time. Assess pain severity. Have the patient rate his/her pain from 0 -10. Document value each time pain is assessed. Non-pharmacological control: Splint injury; apply ice pack.
Use distraction techniques: engage patient in conversation, etc.
Standing orders for controlled substances are found throughout this document.
Listed below is the framework of intent for EMT-Intermediates and EMT-Paramedics to administer Ketamine (Paramedic Only Special Skill) or controlled substances within their Scope of Practice.
AEMT
USE OF CONTROLLED SUBSTANCES
1. In a poly-trauma patient if the patient is in severe enough distress that analgesia would provide a better assessment and allow overall improved patient management, then selective analgesia may be provided with vigilant hemodynamic monitoring.
2. Any patient receiving analgesics will be placed on a cardiac monitor to document cardiac activity, oxygen therapy and ETCO2 to monitor the respiratory side effects of these medications.
3. The highest trained provider (EMT-I or EMT-P) should attend patients receiving narcotics at all times.
4. Antidote: For Hypoventilation from Opiate administration by EMS personnel, administer
a. NALOXONE 0.4-2.0 mg SQ/IV/IO/IM/IN
b. Pediatric: NALOXONE 0.01 mg/kg to 0.1 mg/kg IV/IO/IM/SQ/IN up to 2 mg total dose.
5. Probably safe in pregnancy though animal studies have shown chronic exposure could have adverse effects. If any question contact on-line medical direction.
6. Any administration outside this realm should be done with on-line MEDICAL CONTROL
7. If the patient becomes nauseated after administration of narcotic analgesics consider administration of an anti-emetic agent:
a. ONDANSETRON (Zofran) [4 mg] IV/IO, PO (ODT) or deep IM for adults, or [0.1mg/kg] IV/IO or deep IM for PEDIATRIC.
b. PROMETHAZINE (Phenergan) 12.5-25 mg IV/IO to be diluted in 50 ml of NS administered as a piggy back on a patent IV, or 25-50 mg Deep IM
INTERMEDIATE and PARAMEDIC
No preference for analgesic (Ketamine versus Narcotics) is indicated by the order in this page.
ADMINISTRATION OF KETAMINE (by Special Skill trained Paramedic only)
Adult/Pediatric
0.20 mg./kg. slow IV/IO push over one to two minutes. (10 mg./ml. vial)
May repeat times one in 5 minutes. If protracted contact time the IV/IO dosing sequence of Ketamine may be repeated as needed approximately every 5-10 minutes for continuous pain management.
0.20 mg./kg. IM. May repeat times one in 10 minutes. (10 mg./ml. vial). Additional doses may be administered in approximately 15 minutes as needed for continuous pain management.
ADMINISTRATION OF CONTROLLED SUBSTANCES (Available to Intermediates and Paramedics
Adults
1. FENTANYL 50 – 100 mcg IV/IM/SQ/IN q 5 min until no longer tolerated or pain control achieved.
a. For severe pain may use weight-based dosing: Fentanyl 0.5-1mcg/kg
Pediatric
1. FENTANYL 1 mcg/kg q 5 minutes until no longer tolerated or pain control achieved.
ADMINISTRATION OF KETOROLAC (Toradol) Non-steroidal anti-inflammatory (NSAID) analgesic.
Adults 60 mg. IM (deep in muscle) as single dose in the buttocks. Onset 10 minutes.
For extreme pain may consider 15 mg. slowly administered IV/IO as single dose.
Pediatric (2-16 years) 1 mg./kg. up to maximum of 30 mg. IM. Onset 10 minutes.
For extreme pain may consider 0.5 mg./kg. slowly administered IV/IO maximum 15 mg.
NOTES:
Ketamine and opiate analgesics may be combined if patient is otherwise a candidate for opiate analgesics.
Ketamine preferred as initial agent when support of vital signs (blood pressure and pulse) important such as in trauma patients (See below). Ketamine is effective in controlling pain-associated anxiety when used as an analgesic.
Any patient receiving Ketamine will be accompanied by the administrating Paramedic in the ambulance unless a Ketamine Special Skills Paramedic is available in the ambulance. See Drug Section for more information.
Ketorolac contraindicated in renal failure, L&D patients, breastfeeding, pregnancy.
Ketorolac effective in opioid tolerant patients.
Ketorolac effective in moderate to severe pain. May be combined with other analgesics in these Treatment Guidelines.
Avoid Ketorolac in bleeding (covert or overt) bleeding patients if alternative available.
ALL LEVELS
Routine Patient Care. Consider all patients as candidates for pain control regardless of transport time. Assess pain severity. Have the patient rate his/her pain from 0 -10. Document value each time pain is assessed. Non-pharmacological control: Splint injury; apply ice pack.
Use distraction techniques: engage patient in conversation, etc.
Standing orders for controlled substances are found throughout this document.
Listed below is the framework of intent for EMT-Intermediates and EMT-Paramedics to administer Ketamine (Paramedic Only Special Skill) or controlled substances within their Scope of Practice.
AEMT
USE OF CONTROLLED SUBSTANCES
1. In a poly-trauma patient if the patient is in severe enough distress that analgesia would provide a better assessment and allow overall improved patient management, then selective analgesia may be provided with vigilant hemodynamic monitoring.
2. Any patient receiving analgesics will be placed on a cardiac monitor to document cardiac activity, oxygen therapy and ETCO2 to monitor the respiratory side effects of these medications.
3. The highest trained provider (EMT-I or EMT-P) should attend patients receiving narcotics at all times.
4. Antidote: For Hypoventilation from Opiate administration by EMS personnel, administer
a. NALOXONE 0.4-2.0 mg SQ/IV/IO/IM/IN
b. Pediatric: NALOXONE 0.01 mg/kg to 0.1 mg/kg IV/IO/IM/SQ/IN up to 2 mg total dose.
5. Probably safe in pregnancy though animal studies have shown chronic exposure could have adverse effects. If any question contact on-line medical direction.
6. Any administration outside this realm should be done with on-line MEDICAL CONTROL
7. If the patient becomes nauseated after administration of narcotic analgesics consider administration of an anti-emetic agent:
a. ONDANSETRON (Zofran) [4 mg] IV/IO, PO (ODT) or deep IM for adults, or [0.1mg/kg] IV/IO or deep IM for PEDIATRIC.
b. PROMETHAZINE (Phenergan) 12.5-25 mg IV/IO to be diluted in 50 ml of NS administered as a piggy back on a patent IV, or 25-50 mg Deep IM
INTERMEDIATE and PARAMEDIC
No preference for analgesic (Ketamine versus Narcotics) is indicated by the order in this page.
ADMINISTRATION OF KETAMINE (by Special Skill trained Paramedic only)
Adult/Pediatric
0.20 mg./kg. slow IV/IO push over one to two minutes. (10 mg./ml. vial)
May repeat times one in 5 minutes. If protracted contact time the IV/IO dosing sequence of Ketamine may be repeated as needed approximately every 5-10 minutes for continuous pain management.
0.20 mg./kg. IM. May repeat times one in 10 minutes. (10 mg./ml. vial). Additional doses may be administered in approximately 15 minutes as needed for continuous pain management.
ADMINISTRATION OF CONTROLLED SUBSTANCES (Available to Intermediates and Paramedics
Adults
1. FENTANYL 50 – 100 mcg IV/IM/SQ/IN q 5 min until no longer tolerated or pain control achieved.
a. For severe pain may use weight-based dosing: Fentanyl 0.5-1mcg/kg
Pediatric
1. FENTANYL 1 mcg/kg q 5 minutes until no longer tolerated or pain control achieved.
ADMINISTRATION OF KETOROLAC (Toradol) Non-steroidal anti-inflammatory (NSAID) analgesic.
Adults 60 mg. IM (deep in muscle) as single dose in the buttocks. Onset 10 minutes.
For extreme pain may consider 15 mg. slowly administered IV/IO as single dose.
Pediatric (2-16 years) 1 mg./kg. up to maximum of 30 mg. IM. Onset 10 minutes.
For extreme pain may consider 0.5 mg./kg. slowly administered IV/IO maximum 15 mg.
NOTES:
Ketamine and opiate analgesics may be combined if patient is otherwise a candidate for opiate analgesics.
Ketamine preferred as initial agent when support of vital signs (blood pressure and pulse) important such as in trauma patients (See below). Ketamine is effective in controlling pain-associated anxiety when used as an analgesic.
Any patient receiving Ketamine will be accompanied by the administrating Paramedic in the ambulance unless a Ketamine Special Skills Paramedic is available in the ambulance. See Drug Section for more information.
Ketorolac contraindicated in renal failure, L&D patients, breastfeeding, pregnancy.
Ketorolac effective in opioid tolerant patients.
Ketorolac effective in moderate to severe pain. May be combined with other analgesics in these Treatment Guidelines.
Avoid Ketorolac in bleeding (covert or overt) bleeding patients if alternative available.