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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
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.
Recommendations vary regarding pre-hospital analgesia and it is important to follow local guidelines if available. This article provides a very brief overview. For further information, see Reference and Further Reading links to the British National Formulary (BNF), BNF for Children and pre-hospital management guidelines at the end of this article.
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.
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:
- 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.
- 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 use
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.
- Acute abdomen.
- Delayed gastric emptying.
- Heart failure secondary to chronic lung disease.
Further reading and references
British National Formulary for Children; NICE Evidence Services (UK access only)
Lindbeck G, Shah MI, Braithwaite S, et al; Evidence-Based Guidelines for Prehospital Pain Management: Recommendations. Prehosp Emerg Care. 202327(2):144-153. doi: 10.1080/10903127.2021.2018073. Epub 2022 Jan 25.
UK Ambulance Services Clinical Practice Guidelines 2021; Joint Royal Colleges Ambulance Liaison Committee Guideline Development Group (JRCALC-GDG).
Albrecht E, Taffe P, Yersin B, et al; Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study. Br J Anaesth. 2013 Jan110(1):96-106. doi: 10.1093/bja/aes355. Epub 2012 Oct 11.
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.
Major trauma: assessment and initial management; NICE Guidelines (February 2016)
British National Formulary (BNF); NICE Evidence Services (UK access only)