Assessment and Management of Pain for the BLS Provider

1. Assessment and Management of Pain for the BLS Provider Presence Regional EMS May 2014 Continuing Education

2. Objectives Recognize the importance of pain assessment and management in the Pre-Hospital setting. Discuss some common misconceptions held by EMS providers regarding pain. Demonstrate the use of patient self reporting of pain using a 0-10 scale and other adapted scales Show how the use of OPQRST can help the patient in pain further define what they are feeling. List effective non pharmacological techniques EMS providers can use to help a patient manage pain. Review effective pharmacological management EMS providers can use to help a patient manage pain.

3. 12 Painful Myths: Read each statement and decide if it is TRUE or FALSE Patients with a history of substance abuse do NOT have a right to effective pain management. Infants and small children have such poorly developed nervous systems that they rarely feel severe pain.

4. Sedation or sleeping is an indicator of pain relief. Pain is what the patient says it is. The EMS provider’s personal values and intuition about the trustworthiness of the patient is a valid tool in identifying if the patient is lying about pain.

5. Comparable physical stimuli produce comparable pain in all people. The more prolonged the pain or the more experience a person has with pain, the better the tolerance of pain. Patients expect to have their pain relieved. Lying about the existence of pain is very common.

6. Pain is largely an emotional or psychological problem, especially in a patient who is highly anxious or depressed or who has an unclear physical cause for pain. All real pain has an identifiable physical cause. Visible signs, either physical or behavioral, accompany pain and can be used to verify its existence and severity.

7. What is pain? Pain is defined as an unpleasant (not fun) sensory (response of the nervous system)and emotional(colored by a variety of emotions, fear, anger, despair)experience that is associated with actual (real) or potential (in the process like ischemia)tissue damage.

8. Pain is Subjective The pain belongs to the patient. The patient with the pain is the only authority about the pain The sensation of pain is felt only by the patient. Past experiences and beliefs color perception of pain.

9. Past Experience Past experiences that color the perception of pain may be pain that the patient has had before or experiences in dealing with the pain in the past Patient will report pain based on how it compares to the pain they have had in the past

10. As a Professional Accept and appreciate that only the patient can feel pain. Measure the pain by asking repeatedly

11. Adaptation Adaptation occurs when a patient is experiencing reoccurring or chronic pain. The patient has “gotten used to” the pain. While the pain is still present, the patient will present with normal vital signs and may even appear to be free of pain.

12. Adaptation: Patients who have adapted will appear different than those with a new experience of pain • Acute Pain - New Pain • ↑ Blood Pressure • ↑ Pulse • ↑ Respirations • Dilated pupils • Diaphoretic • Adaptation - Chronic Pain • Normal blood pressure • Normal pulse • Normal respirations • Normal pupils • Dry

13. Acute Pain Adaptation Focuses on pain Does not report Cries and moans Tries to sleep Distracts self Rubs painful part Physically inactive Muscle tension Frowns/grimaces Blank or normal facial expression

14. Contributing Factors There are factors that contribute to how the patient perceives or reports pain. A wide variety of factors can play into how pain is reported to the EMS provider.

15. Contributing Factors Cultural expectations: Some cultures expect patients to complain loudly and dramatically about pain, while some cultures expect individuals to be very stoic and never complain of pain. Recognize the patient’s culture and accept their response to pain accordingly.

16. What is this sensation called again? Particularly with cardiac pain, some patients perceive the sensation not as pain but as pressure or burning. Ask the patient what the sensation is like and refer to the sensation using these words.

17. Past experience with pain: A man who had bilateral femur fractures when he was 16 years old, has some experience with pain so at the age of 60 he may report cardiac chest pain at a lower numerical number. On the other hand, 60 year old man with chest pain who has never experienced much pain in the past, but whose father died of a heart attack at age 60 may report the pain at a very high number.

18. “I don’t want to be a bother” Some patients don’t want to draw attention to themselves or want to make more work for EMS providers , so they will down play their pain.

19. What if they are faking it? Research shows that very few patient lie about having pain that they don’t have. More often patients will down play pain or tell EMS providers they don’t have pain or insist that they have very little pain at all

20. Can you tell by looking at someone who is in pain and who is not? How reliable are your values, beliefs and prejudices?

21. Is there a source for this feeling? All pain has both physical and psychological components. The absence of an identifiable physical cause does not mean the pain does not exist

22. What is with emotions and pain? Anxiety is associated with new onset, brief pain Depression is associated with prolonged pain

23. Individual Responses to Pain What are the cultural expectations for pain? Do they tell you about pain or hold it in? What are the learned expectations? If a patient with chronic pain has not had pain relived in the past, they will not expect to get any help or support from EMS Providers

24. Non-Verbal Behaviors A patient’s non-verbal behaviors can be a blessing or a curse. Patients with chronic pain have adapted to be able to position themselves comfortably in spite of the pain.

25. Nonverbal Behaviors Not all patients that are in pain will exhibit signs. With chronic pain, patients may have adapted to be able to better live their lives with pain. Acute pain may or may not cause a physical reaction such as guarding the affected area. Nonverbal behaviors may not reflect patients level of pain.

26. Nonverbal Behaviors Visible signs unreliable due to adaptation Can you tell who is in pain?

27. Physical Assessment of Pain Palpation is commonly used to assess tenderness. Useful in children, patients with altered mental states, developmentally disabled, and patients who speak foreign languages. May note patient to be guarding area of pain or withdrawing when EMS attempts to assess. Area of pain may be tender when palpated. May also notice DCAPP-BTLS in area of origin of pain.

28. Verbal Assessment of Pain O – Onset P – Palliative/Provocation Q – Quality R – Region/Radiation S – Severity T – Time

29. How is pain measured? Can use 0-10 scale individually or as part of your OPQRST Can use visual aids to measure pain.

30. Onset Can be used to determine what the patient was doing at time the pain began. Helpful in determining what caused the pain. Can be assessed by asking ‘What were you doing when the pain began? Did anything cause your pain?’

31. Palliative and Provocation Used to determine if pain is made worse or better with anything the patient or EMS providers do in attempt to relieve it. Ask ‘Does anything make the pain worse?’ and ‘Does anything make the pain better’ separately to avoid confusion.

32. Quality A descriptor is order to determine what the patient is feeling. ‘What is the pain like?’ Can use helpful terms such as: sharp, dull, crushing, tearing, pressure, throbbing, etc.

33. Region/Radiation Determine the location of the pain. Determine if the pain is localized or if it presents in other locations as well. ‘Where does it hurt?’ ‘Does the pain move anywhere’

34. Severity Use to measure the patients pain. 0-10 scale 0 is no pain and 10 is intolerable pain One measurement is baseline Frequent measurements are needed

35. Time Determine how long this episode has been going on. Can also determine if patient has had this type of pain before and if the pain is constant or not. ‘How long have you had this pain?’ ‘Has the pain been constant or does it come and go?’ ‘Is this the first time you have felt pain like this before?’

36. Pain Tolerance • The amount of pain a person is willing to endure. • Tolerance is a unique response not everyone is the same. • Prolonged or recurring pain with no assurance of relief lowers tolerance. • Make an agreement for pain control. • The patient can give a number 0-10 of how much pain they can tolerate.

37. Techniques to Treat Pain Reassure the patient. Let the patient know that their pain is a priority for you and that they are receiving the help they asked for. Position patient in a position of comfort on the cot. Pad the cot around the patient if necessary. Use heat and cold packs as appropriate to ease pain. Call for ALS to manage severe pain.

38. Pharmaceuticals Available to ALS Providers Upon ALS arrival give report including patients complaint, vital signs, medications, allergies, and medical history. ALS providers have ability to administer Morphine, Demerol, and Fentanyl to control pain. Can also administer Zofran to assist with nausea often associated with administration of analgesic medications.

39. BLS provider and Chest Pain Classic area is sub sternal with radiation to left shoulder, arm, jaw, and back. Chest pain can be caused by Acute Coronary Syndrome. Can lead to damage or death of heart tissue and cardiac arrest. Is a serious condition that BLS providers can start initial treatment for. ALS intercept should be requested.

40. EMT-Basic Treatment of Chest Pain Able to administer medications to assist the patient suffering from chest pain. Oxygen administered at 15lpm via NRB to oxygenate damaged tissue. 325mg ASA administered as a clot inhibitor. Nitroglycerin 0.4 mg given SL up to 3 times for vasodilation of blood vessels. Reassess vital signs between doses of Nitroglycerin. KNOW YOUR INDICATIONS AND CONTRAINDICATIONS!

41. Case Presentation #1 You are called for a 74 year-old female who has fallen in middle of the night. Patient is complaining of right hip pain. Denies any further complaints. Upon arrival you find patient laying in the bathroom. Patient appears to be in a great deal of discomfort. Scene is safe and family is present.

42. General Impression Patient is laying supine on floor guarding her right hip. Note right leg shorter than left with right foot rotated outwards. Patient is in excruciating pain when hip is palpated and when she attempts to move it.

43. Initial Assessment Airway: patent Breathing: 24 breaths/min Circulation: pulse is 120 and BP is 170/100; slightly pale and sweaty Disability: Alert and oriented; unsure of how long she has been on floor Exposure: Tenderness to right hip; shortening and rotation of right leg. No other trauma.

44. OPQRST Onset: Began after falling due to tripping on a rug Palliative: Nothing makes the pain better Provocative: Hurts more when palpate or she moves it Quality: Sharp pain Region: Right hip Radiation: Pain shoots down her right leg Severity: 7/10 Time: Pain has been constant since it began

45. Management Priorities Consider early need of ALS for pain management. Consider need for spinal motion restriction devices. Immobilize leg prior to movement of patient. Pad around patient and pad the voids between patient and backboard in attempts to make patients comfortable. Explain procedures to patient and use personnel appropriately in order to ensure smooth movement of patient.

46. Case Summary ALS arrives on scene and manages patient’s pain. Patient arrives at ED without incident and is found to have a femur fracture just distal to the femoral head.

47. Case Presentation #2 You are called to a local business for a 26 year old female complaining of abdominal pain. Upon arrival you are led to a cubical where you find your patient seated in a chair vomiting into a waste basket. Scene is safe.

48. General Impression and Physical Assessment Patient is seated in chair vomiting into waste basket. Patient is anxious and guarding the right side of her abdomen. Upon palpation of patients abdomen find patient to have increased pain when the lower right quadrant is released. No further physical findings.

49. Initial Assessment Airway: patent Breathing: 24 breaths/min Circulation: pulse is 120 and BP is 110/70; slightly pale and sweaty Disability: Alert and oriented; anxious Exposure: Rebound tenderness to right lower quadrant of abdomen.

50. OPQRST Onset: Pain has been present since she awoke this morning Palliative: Nothing is making the pain better Provocative: It hurts slightly worse when palpated, but much worse when pressure on it is released