Updated 26/2/24

PAIN MANAGEMENT (v3)

Pain is the most common symptom we encounter in MR.  Controlling it is important, not only for the comfort of the casualty, but in some cases to prevent further deterioration, improve physical parameters (heart rate, BP, respiration rate, SpO2 and capillary refill), allow better assessment and management.

Pain relief should be started as soon as reasonably practicable even if a definitive diagnosis has not been reached.  Multiple studies have demonstrated the widespread inadequacy of pre-hospital pain relief and delays in administration of analgesia play a significant role in this. There are reasons to believe this is often the case in MR and this is something we should aim to avoid.

Studies have shown that analgesia administered before pain occurs is better than the same analgesia administered after it occurs at reducing the amount of pain experienced.  Therefore where possible we should take a prophylactic approach and administer analgesia prior to potentially painful interventions such as splinting or packaging.

Remember - pain won't kill a casualty, assessment and treatment of life-threatening conditions through the DrcABC approach MUST always precede the assessment and administration of pain relief.

Causes of Pain

Physical

The physical causes of pain we encounter in MR include the obvious such as broken bones, dislocations, torn muscles and tendons, cuts, grazes, lacerations, bruises, haematomas, ischaemia in a deformed limb, burns and electrical shocks, but also includes less obvious causes such as restricted blood flow to the heart, a tight chest during an asthma attack, insect stings, headaches and migraines.

Where a casualty is in pain from a physical cause we should aim to prevent or minimise further pain from that cause if possible through the use of the physical interventions (e.g. splinting or reduction) or medicines (e.g. GTN or paracetamol) available to use.

Determining the severity of pain

Pain is highly subjective and unique to each casualty. It is influenced by a wide range of factors (e.g. cause, social, cultural, prior history of pain, age, gender, fear, anxiety), one person’s Pain Score of 10 would be another person’s 6. Studies have shown even trained professionals are poor judges of their patients pain, usually underestimating it. Unless there are reasons to believe the casualty is being disingenuous, we should treat according to the reported pain score.

Start by ask the casualty to rate their pain on a scale of 0-10 with 0 being no pain at all and 10 being the worst imaginable.  Also enquire about the nature, duration, location and radiation of the pain.

Ask them to rate the pain now, at the time of the incident, how it has changed and if anything provokes an increase in pain e.g. movement or weight bearing.

Pain scores should be repeated after interventions e.g. splinting or packaging and periodically during the evacuation.  Repeat their previous score to them before asking for their current score.  The trend in scores is a more important indicator of the effectiveness of treatment than the absolute scores.

MANAGEMENT

The key point to bare in mind with management of a casualty's pain is that it should be undertaken as quickly and completely as possible through psychological support, distractions, physical interventions and analgesia.  In some circumstances it may also be possible to treat the underlying cause of pain, for example by giving GTN to a casualty suffering from angina or Entonox when reducing a fracture.

Psychological Support

The psychological element of pain is often forgotten about when we are busy are assessing and treating a casualty, yet it is quick, easy and can start as soon as you say hello. Being sat in pain on a cold windy mountain side, embarrassed at having to call for help, not knowing how long we will take to arrive, what we will be be able to do to relieve their symptoms and what will happen to get them down safely can all lead to mounting fear and anxiety which increases people perception of pain.  By engaging with them in the right way we can allay these fears as well as distracting them from the pain.

To do this we should:

• talk to them from the outset, try to make a human if possible try to get them to laugh, studies have shown it reduces perception of pain.  Failing that let them know they can swear, it also helps reduce perceived pain scores.

• reassure them that it's not their fault they need our help (even if it is!) and they're not being silly or a bother

• support them to sit in a comfortable position

• try to keep them warm, dry and out of the gaze of onlookers

• explain what we're going to do to assess them and that you will give them something for the pain as soon as possible (anticipation of an end or reduction in pain has been shown to reduce perceived pain)

• explain how we will treat their injury to minimise further discomfort

• explain how we will evacuate them

Analgesia

We have a range of analgesia available, depending upon the pain score, stability of the injury, length of evacuation and type of terrain to be navigated through.

In general it's best to start with non-drug methods and then work up the analgesic ladder, adding paracetamol, then ibuprofen, then entonox and finally morphine.

These drugs act on pain through different pathways and can safely be given together (unless contra-indicated by specific injuries or illnesses). Administering several analgesics at once in a process called multimodal analgesia can produce pain relieving effects greater than any of the individual drugs even morphine and should be encouraged for severe pain.

Remember - exclude contra-indications before giving any drugs. Two team members should always check a drug, and one of those team members must have the Cas Care Certificate.

The types of analgesia we carry:

• Entonox -rapid acting, but has a very short half life when inhalation is stopped (meaning it wears off rapidly) . It's useful as the first analgesic whilst other pain relief is instituted and can be used in conjunction with morphine, particularly during painful procedures such as splint application and patient movement.

• Paracetamol - can be used in isolation for mild pain or in combination with any or all of the other analgesic's available in more severe cases.

• Ibuprofen - can be used in isolation for mild pain or in combination with any or all of the other analgesic's available in more severe cases.  Do not use if they have an allergy to NSAIDS (non-steroidal anti-inflammatory drugs e.g. the family aspirin belongs to), or other contraindications.

• Morphine (IM) - morphine is used in casualties with moderate to severe pain (Pain score 6 or greater and for heart attacks 4 or greater).  It can be used in combination with any or all of our other analgesia.  Due to the risk of respiratory depression and sedation, naloxone must be available before morphine is administered.  Do not give in cases of asthma, breathlessness, head injury with a GCS below 15, chest or abdominal injuries with severe hypoxia, hypothermia.

• Fentanyl - is a synthetic analgesic similar to morphine.  It has the same effects and contraindications as morphine, but has a more rapid onset and slightly shorter duration than traditional opioids.  It's also fat soluble (traditional opioids are only water soluble) meaning it can be absorbed through the skin or the oral mucosa (the membrane inside the mouth) and in MR is administered via a lozenge.  It has several advantages, simple rapid preparation, reduced levels of nausea, lower risk of allergic reactions, self administration, it can be titrated. However it requires the casualty to rub it agains the inside of their cheek for a period of 15-20 minutes which precludes the use of entonox and oxygen at the same time. Due to the risk of respiratory depression and sedation, naloxone must be available before fentanyl is administered. Do not give in cases of asthma, breathlessness, head injury with a GCS below 15, chest or abdominal injuries with severe hypoxia, hypothermia.

• Ketamine (doctor administration only) - for severe pain, particularly bone on bone.

How to Administer Entonox

Set up the cylinder by attaching a mouthpiece to the demand valve and then attaching the tubing to the cylinder.  Open the cylinder valve fully then test by listening for a gas sound when you press the button on the back of the demand valve.  Keep the mouthpiece clean as this will be put in the casualty’s mouth.

Explain to the casualty that entonox is a quick acting self administered analgesia which takes effect within minutes if breathed continuously, but also wears off just as quick.

Check the cylinder has not been allowed to cool below 5°C in the previous 24 hours. 

Check for contra-indications including pneumothorax, a head injury with a GCS below 15 or diving accident

Ask them to:

• Put the mouthpiece between their lips or teeth

• Keep it there as they breathe in deeply and evenly through their mouth and out through their nose. The mouthpiece has a two-way valve that releases the gas and air for them to breathe in.

• Continue to breathe deeply and evenly, if they stop the pain relieving effects will wear off rapidly

• If they start to feel a little light-headed or dizzy they should simply take the mouthpiece from their lips and breath normal air. Within a minute they should start to feel perfectly normal again.

When not in use make sure the mouthpiece is covered (you can use a plastic glove) to keep it clean. The casualty does NOT want a mouthpiece that has been put on the ground going into their mouth.

Morphine

Morphine is given in two ways. Intravenously (IV) by the paramedics and Drs and Intramuscularly (IM) by team members who have the Casualty Care Certificate. The Injections Pouch in the Medical sac has everything that is needed for both IV and IM injections. Additional gauze and wound management equipment is in the Wound Pouch in the Fracture sac. The health care professionals will usually start by giving a small dose of Morphine and then more if needed. The IV route into a vein is extremely quick in relieving pain whereas the IM route into a muscle may take up to 20mins to start working and longer if the casualty is very cold.

To prepare the equipment for the IM injection, this will include:

• Nitrite gloves

• a ‘safety’ green needle (or a smaller blue needle if the casualty is very thin)

• a ‘Blunt Fill’ filter needle with filter for drawing up the solution

• a 2ml syringe

• a pre-injection wipe

• a gauze swab

• a plaster

• a sharps bin (yellow)

• a yellow/orange plastic waste bag (Monitoring Pouch) to give you a clean area to work on and to use for any clinical waste material.

• a vial of 10mg morphine sulphate in 1ml

Check the drugs crib sheet for indications, dose, contraindications and possible side effect to monitor for.

Have a qualified casualty carer confirmed it is the right drug, the right dose, the drug is in date and naloxone is available.  Have the dose administered, expiry date and batch number noted on the cas card. The Morphine vial must always be shown to the Cas Carer or healthcare professional who will be giving the drug. They are responsible for the administration of the drug. If the casualty is on blood thinning drugs then ask the casualty if they have had any problems with bleeding after an injection. You will need to press on the injection site for at least 3 mins (could need longer).

Explain the need for injection to the casualty, obtain consent for administration.

I.M Administration

Be aware of the risks of needle stick injury and body fluids contamination to minimise these to yourself, your team mates and the casualty. You must read and understand the section on ‘Sharps Injury & Clinical Waste Management’.

This is a ‘clean’, sterile technique. Care must be taken at all times to ensure that the needle remains sterile. If this touches anything before the injection is given it must be replaced.

• Prepare a ‘clean’ and safe area for you to work in. E.g. place yellow/orange clinical waste bag on the ground by the casualty with all your equipment ready to hand.

• Put on latex gloves. and swab the area with a pre-injection wipe if required. Our preferred location is the outside of the thigh.

• Open syringe package without touching open end of syringe. This must be kept sterile.

• Fit the ‘Blunt Fill’ filter needle to the syringe, keeping the needle cover in place to ensure it is kept sterile.

• Tap ampoule to move all liquid into main body of ampoule. Open, breaking away from face using a medical wipe, gauze or plastic ampule opener, to protect fingers from breaking glass.

• Draw up required dose into syringe, don’t worry about air bubbles at this stage, just get the fluid into the syringe.

• Remove the ‘Blunt Fill’ filter needle and place in the sharps box. Replace with the appropriate ‘safety’ needle for giving the injection. Remove needle cover and activate safety device. Now remove air from the syringe, holding the syringe vertical and tap to release any air bubbles. Gently press plunger until the first drop of medication emerges. See videos of safety needle device and blunt fill filter needle in the section on ‘Sharps injury & clinical waste management’.

• Pull back the skin near the injection site and insert the needle using a dart motion.  This is called the Z-track technique, see teh video below for details.

• Before injecting, withdraw plunger. If blood appears this means the needle is in a blood vessel and should be withdrawn. The needle and morphine will need to be discarded (follow Controlled Drug waste procedure) and a new ampule and needle used. If you were to use the needle and syringe with blood in it at another site you would not be able to tell if there was blood drawn back at the second site.

• If no blood, inject.

• Activate the safety mechanism of the needle and dispose of the needle and syringe into the sharps box.

• Wipe the injection site with a gauze swab and apply a plaster if necessary.

• Record the administration of the drug and monitor for complications e.g. wheeze.

• Once back at base fill out the controlled drugs register.
  
  
  

Fentanyl

Fentanyl interacts with the same receptors in the brain as morphine and has similar analgesic qualities and side effects. Unlike morphine, fentanyl is absorbed through the lining of the mouth. It is available as a ‘lozenge’ (see photo). For all practical purposes in MR, fentanyl is ‘morphine on a stick’ and has the same practical and legal requirements for storage, handling, administration and recording of usage.

Fentanyl and morphine have nearly identical analgesic qualities, and on the rare occasion that a problem arises, side effects can be reversed through the use of naloxone in the same way.

Although available in several doses, most MR teams use the 600 and 800 mcg lozenges (brand name Actiq). The 800 mcg dose is roughly equivalent to 5 mg morphine, if taken correctly (see below), so it can easily be repeated if one lozenge isn’t sufficient. LAMRT carry two lozenges in each drug box.

The lozenge form of fentanyl has several advantages for us:

• Speed and ease of preparation. Just open the packet and hand it to the casualty. This is particularly useful in difficult light and bad weather conditions. Anyone who's tried to prepare and draw up morphine at night in the snow with a strong wind, will know how much of a challenge it can be.

• No potential loss of part of the dose from preparation errors.

• Non-invasive administration. They use it in their mouth.

• No sharps are involved so there is no risk of needlestick injury or risk from blood-borne viruses. Most casualties don't like needles, and most rescuers don't like giving injections so everyone benefits.

• No risk of equipment failures

• It can be used by casualties on warfarin (a drug that interferes with blood clotting - patients taking this should not be given IM injections)

• Ease of disposal

• It's easy to give enough drug to ease/remove their pain. Casualties usually stop using it when they are comfortable. Alternatively, just take it off them once it's had the desired effect

• As it's self-administered, the casualty will stop taking it if they become drowsy or nauseous.

• The Team can get on with other duties whilst the casualty is self-administering the fentanyl.

Advantages of fentanyl over IM morphine

• Slightly more rapid onset

• More predictable effect in patients who are cold or have been bleeding

• Substantially reduced risk of allergic reactions - fentanyl is extremely safe

• Lower incidence of nausea and vomiting

Disadvantages

• Marginally shorter duration than morphine. However, if it wears off during a long evacuation, just give the casualty a second lozenge.

• The casualty must self-administer the drug correctly The drug is absorbed through the lining of the mouth. Any drug that is swallowed is effectively lost. This means that you must spend a few minutes explaining precisely how you want the casualty to use it.

• Ideal administration takes about 15 minutes, so finishing it sooner indicates more has been swallowed.

• We are unable to directly observe how much has been swallowed and how much has been absorbed effectively, therefore it is difficult to tell how much of each lozenge been taken effectively.
  

Who can give Fentanyl?

Any casualty carers with a current certificate who are allowed to give morphine, can administer the fentanyl. 

The indications for fentanyl are the same as morphine. As a rough guide, consider using it for:

• Severe pain e.g. due to a fracture with a pain score of 6 or greater.

• Heart attacks with a pain score of 4 or greater.

Remember - As with morphine, fentanyl can be used in conjunction with Entonox, paracetamol and ibuprofen as part of multi-modal pain relief.

Contraindications

The contraindications for fentanyl are essentially the same as morphine i.e. do NOT use if:

• Asthma

• Breathlessness or respiratory depression

• A head injury with a GCS of less than 15

• Chest or abdominal injuries with severe hypoxia

• Hypothermia

• Injury to the mouth or tongue

• Estimated blood loss >1500 ml; pulse rate >120/min; BP reduced or very low; Respiratory Rate >20; Mental state - confused or drowsy.

There is one additional contraindication that is unique to fentanyl. If the patient is taking ANY antidepressant, do NOT give them fentanyl. This is because there is the potential for a rare, but potentially life-threatening interaction to occur.

Side effects

The side effects are the same as for morphine:

• Nausea and vomiting. This is much less common than after morphine but if it occurs, use Buccastem or Ondansetron to treat it

• Drowsiness

• Respiratory depression

• Hypotension (low blood pressure)

• Reduced pupil size

Dose

The standard adult dose is 600 or 800 mcg in one lozenge.  For children under the age of 16 years, get medical advice or use IM morphine.

Remember - any portion of the dose which is swallowed will have no effect. Therefore the effective dose is likely to be lower than the amount administered.

The protocol allows for a repeat dose of fentanyl to be administered (i.e. a second lozenge) if adequate pain relief has not been achieved by the first.

Administration technique

Always do SAMPLE first to rule out any allergy to the drug.

The key to the correct administration of Fentanyl is good coaching of the casualty.

NOTE: although it is described as a “lozenge”, the end of the stick should not be sucked. The drug should be “painted” on to the lining of the mouth (see video below).

Assess and record Pain Score

• First explain to the casualty what the drug is and inform them that the drug works by being absorbed through their gum and cheek, not by being swallowed. Ask them to try to avoid swallowing whilst taking the drug, as any they swallow won't have any effect.

• Ensure naloxone is available (general precaution before giving any opioid, although rarely needed in MR practice)

• Remove the lozenge from the packaging. Don't discard the packaging. You will need it to put the stick back into, if it has not been finished.

• Hand it to the casualty and asked them to place it between their cheek and gum

• Ask them to run the lozenge back and forth continuously in their mouth whilst twirling the the stick between their fingers in the manner shown in the video below. This should take around 15 minutes.

• Tell the casualty to imagine that the are painting the inside of their mouth with the drug.

• They must not to bite, suck or chew on the lozenge. See here.

• Ask team members to minimise asking questions or talking to the casualty unless necessary. This will reduce the need for the casualty to remove the lozenge to answer your question!!

• If possible, try to minimise movement of the casualty whilst they are taking the lozenge, solely because this could interfere with correct use.

• Repeat Pain Scores at 15 and 30 mins to assess if it is having an effect. Once adequate pain relief has been achieved, the casualty can stop taking the drug, even if it has not been finished. Retain the rest of the dose in case they require further pain relief during evacuation.

• If adequate pain relief hasn't been achieved after one dose and no side effects are present, consider giving a second dose.

• Observe the casualty for side effects throughout, as with all opioids.

• Just like when giving morphine, record the time, dose given, name of administrator and witness on the cas card.

Remember - 15 minutes is quite a long time. As with entonox, the casualty may need repeated coaching to maintain good administration technique.

Disposal of partially finished doses

Remember that fentanyl is a Controlled Drug. Partially finished doses should be kept by a qualified casualty carer whilst on the hill (preferably the individual who administered the dose). Do not allow the casualty to retain the lozenge when they are not taking it.

Once the casualty has been handed over to the ambulance service, dispose of the remaining dose using a CD denaturing bottle. These are kept in the equipment room. Record in the CD register that it has been disposed of appropriately (see legal guidance below).

Legal requirements

The legal requirements surrounding the storage, handling, administration and disposal of fentanyl are exactly the same as those for morphine. These are summarised below.

• Stock must be stored in a 'locked box inside a locked box' i.e. the Drugs safe in the Equipment room

• An annual audit must be undertaken.

• A copy of entries in the LAMRT Controlled Drugs register for each calendar year must be sent to the MREW Medical Officer every 12 moths

• Only administered by an appropriately qualified casualty carer

• Record the date, dose given, name of administrator and witness on the CD register when you return to Base

• Dispose of any unfinished lozenges using the denaturing bottles and record the time of disposal in the CD register, along with the name of the person who disposed of the drug and the witness

The legal requirements for using Controlled Drugs are described elsewhere on this website.