Pre-hospital analgesia

Whilst awaiting transfer to secondary care it is good practice to manage pain effectively. There is well-documented evidence that we are reluctant to treat patients in this way.¹ This may stem from:

• Concerns about patient honesty in evaluating the severity of pain.²

• Concern that it may interfere with treatment necessary after admission.

• Not having appropriate treatments available.

Children are most often neglected, with significant disparities in perception of pain, and in frequency that analgesia is given.³ Documentation of assessment and treatment given is often sporadic.⁴ Non-pharmacological methods of analgesia particularly useful in trauma (such as empathy, ice-packs, elevation, immobilisation and splinting) should not be forgotten.

Immediate pain management in adult trauma

Pre-hospital care is a fast-developing subspeciality. The British Association for Immediate Care (BASIC) provides training for any who feel they could benefit.⁵ Virtually all patients complaining of moderate-to-severe pain are candidates for pain management.

Morphine is potent and should not be used indiscriminately. Entonox® is also available for moderate pain relief. This is contra-indicated in chest injury and head injury associated with reduced Glasgow Coma Scale (GCS).

For pain management in pre‑hospital and hospital settings, the National Institute for Health and Care Excellence (NICE) recommends:⁶

• Assess pain regularly in patients with major trauma using a pain assessment scale suitable for the patient's age, developmental stage and cognitive function.

• For patients with major trauma, use intravenous morphine as the first‑line analgesic and adjust the dose as needed to achieve adequate pain relief.

• If intravenous access has not been established, consider the intranasal route for atomised delivery of diamorphine or ketamine.

• Consider ketamine in analgesic doses as a second‑line agent.

General points:

• Monitor patient observations closely.

• Have naloxone to hand, in case of respiratory depression.

• Use visual analogue scales to document the level of pain before and after treatment.

• Entonox can be used whilst waiting for morphine to take effect.

Contra-indications for morphine use⁷

For all opioids:

• Acute respiratory depression.

• Comatose patients.

• Head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment).

• Raised intracranial pressure (opioid analgesics interfere with pupillary responses vital for neurological assessment).

• Risk of paralytic ileus.

For morphine:

• Acute abdomen.

• Delayed gastric emptying.

• Heart failure secondary to chronic lung disease.

• Phaeochromocytoma.