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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.This may stem from:
- Concerns about patient honesty in evaluating the severity of pain.
- 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.Documentation of assessment and treatment given is often sporadic. 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. Virtually all patients complaining of moderate-to-severe pain are candidates for pain management. The Ambulance Service switched from nalbuphine hydrochloride (Nubain®) to morphine sulfate as first-line management of severe pain. It is the analgesia of choice for myocardial infarction and severe trauma. 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).
- 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.
- Ketamine may have a role in more serious trauma.
|Pain management criteria||Hospital contact||Treatment|
|Any patient complaining of: significant injury to extremities, burns, crush injury, prolonged extrication, severe back/spinal pain; immobilised patients, abdominal pain, journey time >10 minutes.||Not required, unless more than 20 mg morphine sulfate are required.||Oxygen. Intravenous (IV) access. |
Morphine sulfate IV:
|Critical trauma patients with: abdominal trauma or thoracic trauma.||Not needed unless more than 5 mg morphine sulfate are required.||Oxygen. IV access. |
Morphine sulfate, IV or IM, titrated against pain to a maximum of 5 mg.
|Other patients complaining of: head trauma, decreased respirations, altered mental state, women in labour, systolic blood pressure less than 90 mm Hg, journey time less than 10 minutes.||Required.||Contact base physician before giving ANY medication.|
Immediate pain management in paediatric trauma
|Pain management criteria||Base contact required?||Recommended treatment|
|Any patient with significant injury to extremities, burns, crush injury, back or spinal pain, abdominal pain; immobilised patients, journey times greater than 10 minutes.||No. Unless greater than allowed maximum dose or morphine sulfate is required.||Oxygen. IV access. Morphine sulfate as below.|
|Critical trauma patients, including abdominal trauma, thoracic trauma or head trauma. Decreased respirations, altered mental state, journey time less than 10 minutes, blood pressure outside normal range.||Yes.||Contact base physician before giving any treatment.|
Other options used in hopsital settings include intranasal diamorphine or fentanyl.
Contra-indications for morphine use
- Hypertensive patients; diastolic blood pressure greater than 90 mm Hg in adults, 80 mm Hg in schoolchildren or 70 mm Hg in children of preschool age.
- GCS of less than 12.
- Patients taking monoamine-oxidase inhibitors.
- Previous anaphylactic reaction to morphine.
Morphine doses for children
Pain should be documented as a fraction - eg, 3/10. Use visual scales according to age - ie happy/sad faces.
|Drug and route||Recommended dose|
|Oral morphine sulfate||200-400 micrograms per kg every four hours, titrated against pain - eg, 20 kg child dose = 4-8 mg.|
|IV morphine sulfate||50-100 micrograms per kg, titrated against pain, as stat dose.|
|Naloxone||4 micrograms per kg, titrated against respiratory rate.|
Further reading and references
UK Ambulance Services Clinical Practice Guidelines 2016; Joint Royal Colleges Ambulance Liaison Committee Guideline Development Group (JRCALC-GDG)
Haley KB, Lerner EB, Guse CE, et al; Effect of System-Wide Interventions on the Assessment and Treatment of Pain by Emergency Medical Services Providers. Prehosp Emerg Care. 2016 May 18:1-7.
Jones GE, Machen I; Pre-hospital pain management: the paramedics' perspective. Accid Emerg Nurs. 2003 Jul11(3):166-72.
Browne LR, Studnek JR, Shah MI, et al; Prehospital Opioid Administration in the Emergency Care of Injured Children. Prehosp Emerg Care. 201620(1):59-65. doi: 10.3109/10903127.2015.1056897.
Hennes H, Kim MK, Pirrallo RG; Prehospital pain management: a comparison of providers' perceptions and practices. Prehosp Emerg Care. 2005 Jan-Mar9(1):32-9.