Prehospital Pain Assessment and Management

1. Prehospital Pain Assessment and Management An Important Factor in Improving Patient Outcomes Prepared for CCCFTC by MOFD

2. The Purpose of This Presentation To enhance the quality of pain assessment and management for adults and children in the prehospital setting in Contra Costa County

3. Analgesia in the ED • Treatment of pain in the ED is lacking & often delayed • Reasons: • Underestimation of the patient’s need (Most common) • Time required for triage • Time required for MD assessment • Time required to dispense medication • Lilka et al. Academy of Emergency Medicine 2004 • Wilson et al. American Journal of Emerg. Med. 1989

4. But What About the Prehospital Setting? • EMT Perspective • Pain relief has the most potential impact for many prehospital conditions • Expert Panel Perspective • “Most relevant outcome parameter in both adult and pediatric priority conditions” • “The out-of-hospital intervention that might have the greatest effect on patients” Main et al Annals of Emergency Medicine, 1999

5. Is Pain Management Really a Field Priority? • How we practice depends on what we believe… • Agree or disagree? • “A patient should not be medicated for pain until a diagnosis has been made” (36% of field personnel agreed with this FALSE statement) • “Anxiety can affect a patient’s response to pain” (88% agreed with this TRUE statement) • “Pain medication should only be given when pain is severe” (18% agreed with this FALSE statement)

6. Agree or Disagree? • “Increased pulse and respiratory rates, pallor, and perspiration are indicators of pain” (73% agreed with this TRUE statement) • “Patients who are very young have decreased pain receptors requiring less medication” (89% agreed with this FALSE statement) • Patients who receive pain control have improved wound healing (TRUE)

7. Effects of Pain • Poor wound healing • Weakness • Muscle breakdown • Tachypnea +/- shallow breathing • Cough suppression…atelectasis…pneumonia Middleton, C. Nursing Times. 2007

8. Effects of Pain • Sodium and water retention • Decreased G.I. motility • Tachycardia and hypertension • Negative emotions and sleep deprivation • Middleton,C. Nursing Times. 2007

9. EMS System Performance Measure The Contra Costa County EMS System performance goal for pain assessment is 90%

10. How are we doing in adults?

11. How are we doing with children?

12. Co Co PCR Data 2008-2009 • Primary Impressions Associated with Pain • Abdominal pain • Blunt Injury • Burns • Chest pain non-specific • Chest pain ACS • Headache • Non-trauma body pain • Penetrating Injury • Documentation of Pain Assessment • Does not reflect what is actually done. • Pain scales not used • Not documented in the proper place in the ePCR • Frequently forgotten

13. Agency Statistics

14. Universal Issue Although we understand the pathophysiology of pain better than ever, it remains one of the most under-appreciated and under-treated conditions encountered by EMS personnel.

15. Emergency Pain Management Inconsistent and Inadequate • 2000 – White et al., Prehospital Emergency Care Only 1.8% of patients with extremity fx got analgesia • 2002 – McEachin et al., Prehospital Emergency Care; Only 18.3% got Rx for suspected lower extremity fractures • 2003 – Vassiliadis et al., Emergency Medicine; Prehospital and ED femoral neck fractures only received 51% Rx • 2004 – Rupp & Delaney, Annals of Emergency Medicine; Literature review of failure to Rx across wide demographic and treatment settings

16. Estimated that 75% of hospitalized patients with pain are under-treated; ED patients too Large study showed only 44% of patients presenting with long-bone fractures received analgesia Izsak et al., Prehosp. Emerg. Care, April, 2008 Hospital Studies

17. Children often undertreated… • Investigators in a large 2007 study showed there is a void of documentation of assessment and intervention for pain among traumatically injured children… • “no documented pain interventions provided to 85% of subjects with documented pain”! www.JEMS.com. Deschamp, 2006 Management of Pediatric Pain

18. 4/23/09 • Paper presented at NAEMSP Conference… “Despite the availability of analgesic agents to EMS providers, most children do not receive analgesia. Studies identified the inability to assess pain and lack of knowledge on pediatric pain management as potential barriers to adequate pain management.”

19. Healthcare Code of Ethics • Every professional discipline stresses the importance of the alleviation of pain and suffering. • Patients expect EMS providers to acknowledge their pain, assess and treat it.

20. Position Paper - NAEMSP “The relief of pain and suffering of patients must be a priority for every EMS system”. • 2003

21. Assessing/Managing Pain • We all operate from our basic beliefs/ principles/values • What are yours/ours? What are our beliefs about our patients’ pain? • JCAHO Core Principles of Pain Assessment

22. NAEMSP Protocol Recommendations: • Mandatory assessment for presence/severity of pain • Use of reliable pain assessment tools • Indications/contraindications for prehospital Rx • Non-pharmacologic as well as pharmacologic interventions • Monitoring documentation before/after analgesic Rx • Transfer of relevant patient care information to receiving medical personnel • QI/MD oversight of prehospital pain management

23. Alameda County: Fentanyl Study 2008 • Incidental findings: • Overall pain management is improved with provider education and aggressive pain management protocols * *Use of analgesic (Fentanyl) for pain management (n=158) after education on pain assessment doubled, compared to retrospective review of morphine administration(n=83) for the same 6 month time period, one year prior.

24. Assessment Challenges • Infants • Toddlers • Children with Special Healthcare Needs • Geriatrics (Hearing/vision loss, processing problems) • Educational or Language barriers • Cultural differences • Underlying illness/Disability (Stroke, laryngectomy)

25. What Are the Obstacles? • Are there barriers to effectively assessing and treating patients’ pain in your current practice?

26. “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” International Association for the Study of Pain What is “Pain”?

27. Pain is not defined by the amount of observable or suspected tissue damage… Mary John • Dislocated shoulder making an awkward reach • Rates her pain as 20/10 • Clipped his arm on a tree while snowmobiling. Bone ends protruded through the skin. • Rates his pain as 4/10.

28. Classifications of Pain Duration Pathophysiology • Acute – relative to the length of time to heal (trauma, surgery, childbirth, disease ) • Chronic - extends beyond the expected period of healing/ out of proportion to observable causes (injury, disease, cancer, arthritis, fibromyalgia, nerve damage) • Nociceptive • Somatic – surface, localized • Visceral – Poorly localized, like appendicitis, MI (from ischemia, torsion, infiltration, distention, compression, or stretching of organs) • Neuropathic • Nervous system injury/impairment • Centrally generated – stroke, brain tumors, SCI • Peripherally generated – along peripheral nerve pathways (diabetes, infection, pinched nerve)

29. Physiologic Responses to Pain Autonomic Nervous System Stimulation • Sympathetic (catecholemines) • Tachycardia • Increased contractility & cardiac output • Sweating • Tachypnea/Bronchodilation • Nervousness • Parasympathetic (acetylcholine via vagus ) • Bradycardia • Hypotension • Syncope • Nausea

30. Negative Implications of Lack of Pain Control • Increased heart rate, respirations, blood pressure, anxiety and discomfort • Immune, cardiac and respiratory compromise • Long-term harmful effects especially in children • Anxiety, depression, and debilitation • Can lengthen recovery time and hospitalization

31. Pain: The 5th Vital Sign • Begin your pain assessment as you take the vital signs. • First, reassure patient that you acknowledge the pain, and will identify, quantify and treat the source. • Assist patients in communicating pain perception with a pain assessment tool.

32. OPQRST Mnemonic • Memory device • Is pain somatic or visceral? These questions help us classify the pain physiologically.

33. Four perspectives of pain assessment • Physiologic • HR, BP, RR, Skin signs • Behavioral • Useful in infants, toddlers, communication-impaired • Observational • FACES scale • Self-report • Most reliable indicator, especially > 7 y.o. • Variable in 3 – 7 y.o. • Not feasible in < 3 y.o.

34. Pain Assessment Scales • Adult • Numerical • “Rate your pain on a scale from 1-10; 1 being none, 10 worst” • Use prior to and repeatedly after treatment • Verbal • Give a sheet of paper listing 5 pain levels: none, mild, moderate, severe, unbearable • Visual analog • Give a 100mm ruler with “no pain” at left end & “most intense pain imaginable” at right end; pt. slides a cursor to level that best matches his pain

35. Best for Ages > 3 • Wong-Baker Faces Pain Scale • Patient is shown a lineup of 8 faces showing different expressions • Asked to select face he feels best reflects his current pain

36. Infants and Special Needs Children(2 mos-7 yrs) • FLACC

37. Patients with Dementia/Cognitive ImpairmentPAINAD: Pain Assessment for Advanced Dementia

38. Intubated, Non-communicative • Be patient • Use behavioral clues • Grimacing, tears, guarding to palpation • Take physiologic measurements • Increased pulse, respirations, fever

39. Management Options • Nonpharmacologic Interventions (BLS) • Therapeutic communication • Reducing anxiety should always be the first step (simple statements of concern) • Distraction – Conversation, touch, guided relaxation techniques for muscular pain • Immobilization/elevation of extremities/position of comfort • Padding of splinting devices/properly applied backboards or splints • Cold therapy/ Ice pak • Adjust ambient temperature

40. Pharmacologic Intervention (ALS) • Utilize adjunctive non-pharmacologic interventions concurrently • Review of Contra Costa County Pain Protocols

41. Indications and contraindications • Providers must be aware of the pharmacology and complications of every analgesic in their protocols. • Question long-standing dogma! • Withholding analgesia for acute abdominal pain • Old myth that MS is frequently associated with dangerous adverse effects • Risk of addiction • Exaggerated fear of respiratory depression, hypotension in children • Fear of overdosing patients

42. Despite Your Best Efforts…

43. Documentation is critical! • Clinical status of patient before and after analgesia • Monitoring of mental status, blood pressure, heart rate, respiratory rate, cardiac monitoring, SpO2 • Serial assessments of adequacy of analgesia using a pain scale

44. Transfer of Information to Receiving Facility • Medication • Dose • Route • Time • Patient response • Side effects or complications

45. Outcome Measure • Reduction of patient’s perceived pain • Measure repeatedly from time of initial patient assessment to transfer of patient care • Record/report with vital signs • Document appropriately

46. Summary • Patients expect and deserve acknowledgment, assessment, and management of their pain in the prehospital setting • Pain must be assessed to be effectively treated • Effective pain management can be non-pharmacologic as well as pharmacologic • Documentation and reporting of prehospital pain assessment and management to receiving healthcare providers is essential to the continuum of care • Prehospital Providers can make a huge impact on patient outcomes with conscientious assessment and management of pain in the field!

47. The End!