1. ACUTE PAIN MANAGEMENT FOR EMS
DAN MUSE, MD

2. HOW PAIN OCCURS

3. INFLAMATION
ACUTE INJURIES CAUSE INFLAMMATION RESULTING IN PAIN TO THE DAMAGED TISSUE
Tissue Injury: Contusions, Burns, Lacerations, Crush Injuries…..
Bone Injury: Fractures, Dislocations, Sprains, Deep Bone Contusions…..

4. STRETCHING & SEVERING OF NERVES RESULTS IN PAIN
NERVE INJURY
STRETCHING & SEVERING OF NERVES RESULTS IN PAIN

5. PATHOPHYSIOLOGY

6. PAIN PATHWAY
At the simplest level, tissue or nerve damage occurs which causes inflammation or direct nerve injury. This results in signals being sent to the brain that damage has occurred to the body. The subjective response by the body to the injury is PAIN.

7. Controlling inflammation
MANAGEMENT
TOOLS IN THE TOOLBOX
Controlling inflammation
Direct analgesia

8. CONTROLLING INFLAMATION
ICE
Reduces inflammation (swelling) which assists in reducing pain.
IMMOBILIZATION
Reduces movement which in turn assists in preventing further tissue swelling and direct nerve irritation.

9. ANALGESICS
KETOROLAC
IBUPROFEN
ACETAMINOPHEN
FENTANYL
MORPHINE

10. NONSTEROIDAL ANTIINFLAMATORY DRUGS
NSAIDS
NONSTEROIDAL ANTIINFLAMATORY DRUGS

11. NSAIDS
Treats pain by blocking the production of PROSTAGLANDINS

12. NSAIDS
PROSTAGLANDINS
PATHWAY
PROSTAGLANDINS are released when inflammation occurs and assist in sending a signal to the brain that something is wrong (PAIN).

13. KETOROLAC PARAMEDIC STANDING ORDERS ADULT
Ketorolac 15 mg IV or 30 mg IM.
PEDIATRIC
Ketorolac 0.5 mg/kg IV or IM to max 15 mg.

14. IBUPROFEN PARAMEDIC STANDING ORDERS ADULT Ibuprofen 600 mg PO.
PEDIATRIC
Ibuprofen 10 mg/kg PO to max 600 mg.

15. OEMS CONTRAINDICATIONS
NOTE: All pain medications have contraindications-do not administer medications in such circumstances. These contraindications include but are not limited to:
Ketorolac and ibuprofen are contraindicated in head injury, chest pain, abdominal pain, or in any patient with potential for bleeding, ulcer, or renal injury; likely to need surgery
Ketorolac and ibuprofen are contraindicated in pregnancy.

16. CONTRAINDICATIONS AVOID WITH Renal Failure or Renal Insufficiency.
Anticoagulants (excluding daily aspirin).
History of Ulcers
Children under 6 months.

17. NSAID SUMMARY
IBUPROFEN AND KETOROLAC are great alternatives to opioids in the setting of extremity injuries and minor trauma including chest and abdominal complaints that are felt to be muscular or skeletal injuries.

18. ACETAMINOPHEN

19. ACETAMINOPHEN
Acetaminophen is effective as an antipyretic and for treatment of mild to moderate pain.
How it works is not completely understood.
It has very little anti-inflammatory properties.
It is broken down in the liver.

20. ACETAMINOPHEN PARAMEDIC STANDING ORDERS ADULT
Acetaminophen 1000 mg PO. 
PEDIATRIC
15 mg/kg PO to max 1000 mg. 

21. CONTRAINDICATIONS AVOID WITH Liver failure or liver disease.
Those who have been drinking alcohol.

22. OPIOIDS
Fentanyl
morphine

23. OPIOIDS
Morphine: Semisynthetic analgesic. Fentanyl: Synthetic analgesic.

24. OPIOIDS
Treat pain by blocking the pain receptors in the brain, spinal cord and other parts of the body.

25. OPIOIDS
Opioids are effective in the treatment of moderate to severe pain.
Useful in the treatment of heart attacks.

26. OPIOIDS
SIDE EFFECTS: Cause an altered mental status slowing down the respiratory rate and ability to focus and concentrate. Morphine (not fentanyl) can cause hypotension via the release of mast cells in the body.

27. OPIOIDS
CAUTION: AT HIGH DOSES OR IN COMBINATION WITH OTHER SEDATIVE DRUGS AND/OR ALCOHOL, THE PERSON MAY STOP BREATHING.

28. OPIOIDS PARAMEDIC STANDING ORDERS ADULT
Morphine Sulfate 0.1mg/kg IV/IO/IM/SC;
Fentanyl 1 mcg/kg slow IV/IO/IM/IN weight based (kg) to a max of 150mcg (150kg). 
PEDIATRIC
Morphine Sulfate 0.1 mg/kg IV/IO/IM/SC (maximum individual dose 5 mg);
Fentanyl 1 mcg/kg to max 150 mcg slow IV/IO/IM/IN. 

29. NAUSEA
ONDANSETRON

30. ONDANSETRON
Treating the cause of the pain will typically resolve the nausea.
It works by blocking Serotonin which causes vomiting.

31. ONDANSETRON PARAMEDIC STANDING ORDERS ADULT
4 mg IV/IO/IM or PO-oral disintegrating tablet (ODT). 
PEDIATRIC
For child under or up to 25 kg 2 mg IV/IM or ODT; for a child over 25 kg, 4 mg IV/IM or ODT. 

32. ONDANSETRON CONTRAINDICATION:
In pregnancy the medication is considered class B. There is no evidence of risk to the fetus. HOWEVER NOT APPROVED BY FDA IN PREGANCY…..BUT IT WORKS!