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Skidmore College, Saratoga Springs ​[Music] this presentation is to talk about some of the general thoughts behind pain management while the latter half of the presentation will focus on als treatment of pain we will spend some time discussing BLS treatments so why do we care about pain management nationwide pain from any number of sources is a primary reason patients seek care in the emergency room here in Yosemite we provide ample opportunities for patients to hurt and break themselves and to do so in areas that are difficult for us to extricate them from there's growing concern about harmful side effects of painkillers particularly narcotics but on the flip side nationwide studies have shown that emergency medical providers often fall short of addressing patients pain although you somebody EMS providers are often faced with patients in acute pain whether trauma or medical and periodically seek chronic pain concerns I want to take some time to review some of the basic tenets of pain management and discuss overall pain management goals in Yosemite EMS so what is pain pain sensors and sensory nerve cells or neurons are found in nearly every location on the human body and respond to stimuli such as pressure pain and temperature these neurons convert the stimuli into electrical impulses which are sent to the spinal cord and enter into the sensory cortex of the brain fast traveling pain impulses will be sensed by the brain in about one tenth of a second from the time and stimulation the concentration of pain sensors affect how the how a person feels the pain areas of the body such as the fingertips that have a high concentration of pain sensors will be much more sensitive to pain than an area with a low concentration of pain sensors such as abdomen pain originating in areas with low concentrations of pains Zuri's will be described as a key and defuse and have other nonspecific complaints sensory nerve cells that run adjacent to other sensory nerve cells may send overlapping signals to the brain this causes the referred pain phenomenon where a patient senses pain in an area different from where the painful stimuli occurred a common example of this is left arm pain with cardiac chest pain how does the body react to pain pain sensations are the body's way for tissue to tell the brain it is being damaged and that it needs to react to preserve itself initially in response to painful stimuli the sympathetic nervous system will be kicked into gear epinephrine will be released and in response pulse and blood pressure will increase along with other effects patients that are unable to fully activate the sympathetic system such as patients taking beta blockers may have a different presentation in response to pain additionally some patients may stimulate the vagal nerve in their reaction to their pain which would increase the parasympathetic response and present with bradycardia or hypotension when the brain senses pain it will read also release endorphins which bind to opiate receptors on the neurons and thus decrease the pain impulses opioids work in the same receptors within the neurons that decrease the pain impulses pain is subjective well providers can visualize certain injuries that cause pain a provider cannot quantitatively measure pain as they do a pulse or blood pressure the only real measurement providers have of a patient's pain is what the patient says it is to a certain extent providers use other clues to determine the level of pain a patient is experiencing the patient's demeanor is often a huge clue though not always a reliable source since patients react differently to pain visible injuries can help us determine how much pain a patient is XP but patience may often be insignificant pain without obvious deformities because of the difficulty in assessing pain a thorough assessment is critical particularly for pain without an obvious cause having the patient quantify the pain on the one-to-ten spain scale having them use a different word to describe it such as a key stabby a key stabbing or squeezing and also finding the exact areas of pain or referred pain is important pain as an assessment tool throughout EMS there has been a fear that if we remove a patient's pain sensation providers down the chain will not be able to fully assess the patient this is a particularly widespread belief with abdominal pain withholding pain medications due to future assessment concerns is not the right option however it is imperative that the provider completes the thorough examination prior to pain medication administration in cases where there is not an objective cause of the pain and that the provider gives a detailed hand off to the next provider providers can also consider the duration of the pain medications they are giving for example it might be appropriate to administer fentanyl which is relatively short acting instead of dilaudid which is much longer acting so the patient has a better sense of their pain when they arrive at the emergency room within us Yosemite EMS always call medical control prior to administration of pain medication for abdominal pain chronic pain patients may be experiencing chronic pain from a variety of sources whether medical conditions such as fibromyalgia or diabetes or chronic injury such as back pain cancer pain is often classified completely separately from acute or chronic pain as a stimuli is acting on a completely different system EMS generally does not see patients solely because of chronic pain patients may however be experiencing breakthrough pain or pain that is beyond the patient's baseline

this may be caused by unusual activity such as a chronic back pain and who decides to hike up to Nevada falls or there may be no apparent cause for the increase in pain providers may also encounter chronic pain patients who have an unrelated injury such as the back pain patient who trips and Falls and breaks their wrist on the way up to Nevada Falls while treating a patient with baseline chronic pain by administering narcotics may not be the best treatment option EMS should treat break through pain or other causes of pain for chronic pain patients patients who experience chronic pain may require a higher dose of narcotics to achieve the same effect be sure to ask about other types of pain killers of Haitian is on both controlled and over-the-counter and call medical control if you have any concerns about medication interactions pain is not static a patient's pain level may fluctuate during the call the patient may be moved moved or move themselves resulting in an increase in pain injuries may also swell during transport which would further increase the pain level just because a patient begins reporting their pain at a certain level does not mean it will not change in either directions providers can anticipate certain changes in pain level such as when they're going to splint an injury or move a patient I have here a very rough graph of changes in a pain level based on a call initially the pain may speak spike because of splinting or moving the patient then generally decreases as a patient becomes less mobile injury may swell during transport increasing the pain level and also when the patient is transferred to the receiving hospital or ambulance the pain will again increase for a short short duration we will come back to this chart in a couple slides so treating pain BLS methods narcotic administration is not the only way EMS treats pain but providers but as providers we often neglect some of the simpler pain management techniques some BLS techniques to remember and try before moving on to ILS techniques our position of comfort placing a patient in the position of comfort on the cot or making them more comfortable where ever you might have found them in order to perform an assessment placing pillows or blankets beneath the patient's knees may make the long ride on the ambulance far more bearable as well splinting a well applied splint not only decreases the chance of further injuring the patient but minimizes movement within the injury resulting in less pain properly forming and padding splints will affect the patient's pain level ice pack icing injuries will reduce swelling which will reduce pain levels while icing is an important part of injury management don't over ice the injury or apply cold packs directly to the skin distraction techniques patients who have nothing better to do than think about their pain will report higher pain levels this is a great time to play up your bedside manner and keep the patient's mind occupied ALS pain medications Yosemite EMS has several different controlled substances that they'll use to manage pain including fentanyl which is a potent synthetic opioid with an onset within a couple of minutes and a maximum duration of approximately 30 minutes dilaudid or hydromorphone is a synthetic opioid with an onset of five minutes and a maximum duration of four to five hours toradol or ketorolac is a potent non-steroidal anti-inflammatory drug or in said with an onset within 20 minutes and a duration of four to six hours ketamine is a general anesthetic that at lower doses creates a mild dissociative effect onset is within a minute and total duration is 10 to 20 minutes versed or admitted as midazolam is a benzodiazepine with an onset of two minutes and a duration of 20 to 30 minutes the assembly's protocol does not include any pain management indications however in certain cases with medical control contact versed may reduce a patient's pain when pain is caused by muscle spasms for example a patient with a fractured femur begins experiencing extreme pain from legs muscle spasms and cramps if frou said was administered it would help relax the muscles thereby decreasing pain again this is only an indication when contacting medical control using ALS pain medications together when considering which pain medication to administer consider what you are trying to accomplish are you trying to reduce pain for a long or short duration does the patient have to be extricated splinted or otherwise jostle de bout a common pattern for EMS calls is again depicted here with my very poor charting ability again just as a review beginning of the call when the patient has moved more frequently pain level goes up goes down as they become more sedentary and it may fluctuate through transport based on swelling and again at the end of the call when the patient is being moved a pain level goes up if we anticipate some of these pain increases and decreases we can better utilize a range of medications to appropriately manage the patient's pain so to further expand on and demonstrate my very poor Microsoft Paint charting techniques we now have a few more lines in this chart in this chart an example of a combined pain management plan is shown the orange lines are ketamine doses the purple are fentanyl and the blue dilaudid the Green Line is the perceived pain by the patient after pain medications are given and we still have the red line based on the patient's perceived pain without any pain medications let's say that this patient has an isolated extremity injury such as an open tib-fib fracture the patient is in considerable pain when EMS arrives soon after the patient completes a rapid assessment and determines pain management is appropriate prior to moving or splinting the patient an initial dose of ketamine i n is given then shortly thereafter a dose of fentanyl after a couple minutes when the medication begins taking it the patient is splinted and packaged which the patient still perceives as painful just not as much ii doses of ketamine and fentanyl are given during this process as the patient is loaded into the ambulance the providers start thinking of longer-acting pain

management a first dose of dilaudid is given which maintains the patient's pain level for most of the transport ten minutes or so before the transfer to the second ambulance a second dose of dilaudid is given in anticipation of both effect wearing off in the upcoming movement of the patient of note with this call his pain medications were used somewhat fluidly initially the patient received ketamine then once the heightened pain stimuli was removed ketamine was withheld the provider also switched from fentanyl to dilaudid once longer acting pain medications became appropriate the provider also anticipated and administered doses of pain medications wearing off the second dose dose of both ketamine and fentanyl were given well before the first dose wore off avoiding the peaks and valleys effects of waiting until a patient's pain level is increasing before administering a second dose additionally if you notice the pain patients pain level never goes away entirely setting up realistic expectations for your patient that you are managing the pain and helping reduce the pain but not taking it away completely will have them perceive a better effect drug seekers use somebody' EMS compared to other EMS systems serving a more stationary clientele probably probably sees fewer patients who are actively seeking narcotics however providers should always fully assess the patient and situation determine the best course of action use so many EMS also does establish relationships with residents of the valley and may see a pattern of behavior develop with certain patients regardless of one's history with a patient always treat the patient based on his current situation instead of the patient's history generally speaking a pre-hospital provider does not and should not bury the same burden as doctors when determining if a patient truly is experiencing pain in the pre-hospital setting it is very difficult to determine what the true nature the patient's situation is in general EMS providers should always assume the patient is telling the truth about those symptoms until specific points in their story or assessment proves them wrong don't assume that a patient based solely on your past knowledge of them or the initial appearance of the call is seeking drugs and not experiencing real pain until you complete a thorough assessment most drug seekers are looking for a prescription not a single dose from EMS which reduces the burden on EMS providers however inconsistencies to look for in your assessment or in the patient's story is our drug allergies to multiple medications except for the one they're seeking the patient articulating the exact drug and dose that they'd like to control their pain a patient refuses to consider other treatments or medications such as icing or ibuprofen also look for evidence of prescription drug abuse such as an inappropriately large quantity of medications again thanks for bearing with me through this presentation let me know if you have any feedback and remember to complete the quiz in order to get credit for the CES and for the ketamine sign off The Bronx (extension campus).