Quality of pain management in EMS ought to be studied, and I will bet the ranch that a valid study would show that it's seldom done well.
But I would also like to see a study of pain management in the ER. I'm betting that it would show significant deficits in pain management there also.
There seems to be some sort of culture in EMS and EM that pain management should be limited because of perceived abuses by a few patients and some long-ago dismantled notions that analgesia prevents the surgeon from adequately assessing abdominal pain and so forth.
We forget that EMS does NOTHING without a physician's order, and when EMS pain management is lacking, the fault is properly laid at the feet of the physician medical directors.
There are many factors contributing to the reluctance of medical directors to authorize appropriate pain management, one of which is the absolute stupidity of the US Government's position, as promoted by the DEA, that all pain management is somehow suspect, and that physicians who engage in pain management practice are somehow encouraging drug abuse.
No wonder that EMS medical directors are reluctant to write standing orders for adequate analgesia.
I know I'm jumping in here a little late, but not only do I think that parenteral pain management means ALS, but I think it's one significant argument for the existence of ALS EMS. Think about what proportion of our patients present with some type of pain versus what proportion presents with the most studied prehospital complaint--cardiac arrest. Has anyone studied the quality of pain management as a key performance measure for an ALS (or BLS, for that matter) EMS system? Admittedly, pain management doesn't usually appear to influence mortality like cardiac arrest or STEMI management, but is it not as "worthy" a KPI? I think that every patient in pain would think so!
Laurie
Laurie A. Romig, MD, FACEP Medical Director Pinellas County EMS
"This transmission may contain confidential health information that is legally privileged under the State of Florida Statute 401.425. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to destroy the information after it's stated need has been fulfilled. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents."
-----Original Message----- From: naemsp-dialog@googlegroups.com [mailto:naemsp-dialog@googlegroups.com] On Behalf Of Keith Wesley Sent: Monday, September 20, 2010 2:05 PM To: naemsp-dialog@googlegroups.com Subject: Re: [NAEMSP Dialog] Prehospital Pain Management
Dr. Isenberg's question is vital. Do you have policy for which patients go ALS vs. BLS? I do and need for perenteral pain management is ALS.
Keith Wesley, MD Medical Director HealthEast Medical Transportation St. Paul, MN
On Sep 19, 2010, at 8:55 PM, Derek Isenberg wrote:
> One issue that I have not been able to resolve is that in tiered EMS systems, patients that may need analgesia are triaged to BLS > units. For example, the fall with arm/hip fracture or headache may be triaged to BLS providers.
> How do we reconcile this?
> Derek Isenberg, MD, NREMT-P > Medical Director > Mercy EMS
> Mercy Catholic Medical Center > Department of Emergency Medicine > 501 South 54th Street > Philadelphia, PA 19143 > 215.748.9740 > 215.748.9208 (fax)
> On Sep 19, 2010, at 9:07 PM, Dailey, Michael wrote:
>> Gene,,
>> Great topic. In 2008 we did a survey of states to find what analgesics were available for EMS. 26 states allowed fentanyl to be used, 25 on standing orders, with one requiring physician contact. This is up by about 30% from 4 years prior, so there are changes happening across the country. When we worked to add fentanyl to the New York State formulary in 2007 we were met with great resistance by the regulators, who were concerned about the perception of loose controls on EMS and the high propensity for diversion of fentanyl. We made the case, and have a successful, although restrictive program in New York. In NY we have 18 regions, each with different protocols, but all approved by a State Bureau of Narcotics Enforcement, Bureau of EMS as well as Medical Advisory Council and EMS Council--an arduous process to change protocol and formulary, but possible. For now, study the problem, optimize pain management with morphine, and find the pathway that it takes to negotiate the way through the regulators. Dr. Galinski highlights a reasonable protocol for rapid titration of very small doses of morphine that may serve as a stepping stone for you.
>> I was convinced from my practice in EMS and in the ED that fentanyl was the best choice of prehospital opiate before I added the use of the mucosal atomizer to my skill set, and now I am even more convinced. Fentanyl intranasal is hands down the best way to management acute traumatic pain in children, and for adults, the rapid onset, short half-life, minimal histamine release and hemodynamic profile make it the all-round best agent. Dr. Galinski's study comparing F and M was small and had a non-significant trend toward better relief with F. More than anything else it, and work by others including Gallagher in the ED, have demonstrated that the best way to get relief of pain for our patients is to give those administering analgesia the latitude to give more if needed.
>> As Dr. Galinski says, the treatment must "be adapted to pain intensity, patient and pathology." Our providers have the skill to manage pain; we need to give them the tools they need to do it.
>> MD
>> Michael W. Dailey, MD FACEP >> Director of Prehospital Care and Education >> Associate Professor of Emergency Medicine >> Albany Medical Center >> 518/ 262-3773 >> ________________________________________ >> From: naemsp-dialog@googlegroups.com [naemsp-dialog@googlegroups.com] On Behalf Of Wegandy [wega...@aol.com] >> Sent: Saturday, September 18, 2010 23:02 >> To: naemsp-dialog@googlegroups.com >> Subject: Re: [NAEMSP Dialog] Prehospital Pain Management
>> One aspect that has not been discussed is restrictive state mandated protocols that limit a medical director's ability to choose appropriate analgesics for those paramedics working under her/his license.
>> For example, Arizona, USA, where I live, has very archaic and restrictive protocols which must be adhered to by all EMS services. Morphine is the only opioid allowed. Paramedics are not allowed to give fentanyl. Only nurses can give fentanyl in the field, which at least allows flight nurses to use it. AZ also has a system of base hospitals that mandates that every EMS service be tied to a base hospital. The base hospitals have what are called "prehospital coordinators" which are always nurses, most of which have never spent more than an hour or two in an ambulance. One of them said to me that "fentanyl has no place in EMS. Our ER doctors cannot even use it."
>> When one lives in a place like Arizona, it's useless to discuss choices in prehospital analgesia because there are none. And it's useless to discuss titration, because the state protocols do not mention it. They call for set doses, regardless of patient weight or other factors that might enter the minds of somebody who knew what s/he was doing.
>> As an EMS educator, I go beyond state protocols and teach my students the theories of pain management, but they will never be able to use them if they practice in Arizona.
>> I would be interested to know whether or not other states have such restrictive rules.
>> Hi >> About the treatment of pain: >> We have two principles >> 1 - the treatment has to be adapted to pain intensity, patient and pathology >> 2 - the different pain killer should be associated (multimodal analgesia) >> For sever pain (VAS or NRS equal or upper than6/10 or VRS =4), the reference is >> morphine. >> Studies comparing morphine with fentanyl or sufentanil showed that there was >> not difference for relief pain at 30 minutes. (Galinski et al Am J Emerg med >> 2005; Bounes et al Ann Emerg Med 2010). >> Morphine is titrated. In emergency department, patients with VAS equal or upper >> than 7/10, an IV injection of 3mg or 2mg (if weight lower than 60 kg) every 5 >> minutes resulted in a pain relief in more than 80% of patients (lvovschi et al >> am j emerg med 2008).
>> Other pain killers are: non steroidian anti inflammatory drugs (NSAI), >> paracetamol, nitrous oxid. All this treatment can be associated togother and >> with morphine. The association of NSAI with morphine, decrease the risk of >> morphine side effect reducing the dose for the same pain relief.
>> Concerning ketamine: low doses of ketamine (0,1 to 0.3 mg/kg IV) has been >> demonstrated efficient in post operatve setting reducing dose and side effects >> of morphine, and improving analgesia in some cses . But in prehospital setting >> there is currently only one study (controlled and randomised study) which >> demonstrated a reduction of morphine comsumption. But
I would take a slightly different take on this. I don't see the sub-culture saying it should be limited because of a perceived abuse, but I see a sub-culture that has developed over the last "few" years where patients have to somehow prove that their problem is legit. I see many, many pre-hospital providers that emit a perception that "they are faking it" or "they are a drug seeker" or (and my favorite) "oh, they have anxiety, this can't possibly be an actual cardiac event" and these perceptions can, if not properly addressed and corrected, lead to a lack of pain management or an attitude of "they don't need anything" despite the complaint and actions of the patient.
I do have another other question for the group. Have you seen or could you possibly see an issue where the drive to protect the security of the controlled medications leads to the development of processes that are so onerous that the medics do not administer them except in the most extreme cases because they do not want the hassle of wasting, replacing and documenting their use? With the increase in drug diversion in the pre-hospital environment, (at least in Texas) how do we balance security with ease of obtaining/administering?
Dudley Wait Schertz EMS
________________________________
From: naemsp-dialog@googlegroups.com [mailto:naemsp-dialog@googlegroups.com] On Behalf Of Wegandy Sent: Wednesday, September 22, 2010 3:25 AM To: naemsp-dialog@googlegroups.com Subject: Re: [NAEMSP Dialog] Prehospital Pain Management
Laurie,
Quality of pain management in EMS ought to be studied, and I will bet the ranch that a valid study would show that it's seldom done well.
But I would also like to see a study of pain management in the ER. I'm betting that it would show significant deficits in pain management there also.
There seems to be some sort of culture in EMS and EM that pain management should be limited because of perceived abuses by a few patients and some long-ago dismantled notions that analgesia prevents the surgeon from adequately assessing abdominal pain and so forth.
We forget that EMS does NOTHING without a physician's order, and when EMS pain management is lacking, the fault is properly laid at the feet of the physician medical directors.
There are many factors contributing to the reluctance of medical directors to authorize appropriate pain management, one of which is the absolute stupidity of the US Government's position, as promoted by the DEA, that all pain management is somehow suspect, and that physicians who engage in pain management practice are somehow encouraging drug abuse.
No wonder that EMS medical directors are reluctant to write standing orders for adequate analgesia.
I know I'm jumping in here a little late, but not only do I think that parenteral pain management means ALS, but I think it's one significant argument for the existence of ALS EMS. Think about what proportion of our patients present with some type of pain versus what proportion presents with the most studied prehospital complaint--cardiac arrest. Has anyone studied the quality of pain management as a key performance measure for an ALS (or BLS, for that matter) EMS system? Admittedly, pain management doesn't usually appear to influence mortality like cardiac arrest or STEMI management, but is it not as "worthy" a KPI? I think that every patient in pain would think so!
Laurie
Laurie A. Romig, MD, FACEP Medical Director Pinellas County EMS
"This transmission may contain confidential health information that is legally privileged under the State of Florida Statute 401.425. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to destroy the information after it's stated need has been fulfilled. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents."
-----Original Message----- From: naemsp-dialog@googlegroups.com [mailto:naemsp-dialog@googlegroups.com <mailto:naemsp-dialog@googlegroups.com?> ] On Behalf Of Keith Wesley Sent: Monday, September 20, 2010 2:05 PM To: naemsp-dialog@googlegroups.com Subject: Re: [NAEMSP Dialog] Prehospital Pain Management
Dr. Isenberg's question is vital. Do you have policy for which patients go ALS vs. BLS? I do and need for perenteral pain management is ALS.
Keith Wesley, MD Medical Director HealthEast Medical Transportation St. Paul, MN
On Sep 19, 2010, at 8:55 PM, Derek Isenberg wrote:
> One issue that I have not been able to resolve is that in tiered EMS systems, patients that may need analgesia are triaged to BLS > units. For example, the fall with arm/hip fracture or headache may be triaged to BLS providers.
> How do we reconcile this?
> Derek Isenberg, MD, NREMT-P > Medical Director > Mercy EMS
> Mercy Catholic Medical Center > Department of Emergency Medicine > 501 South 54th Street > Philadelphia, PA 19143 > 215.748.9740 > 215.748.9208 (fax)
> On Sep 19, 2010, at 9:07 PM, Dailey, Michael wrote:
>> Gene,,
>> Great topic. In 2008 we did a survey of states to find what analgesics were available for EMS. 26 states allowed fentanyl to be used, 25 on standing orders, with one requiring physician contact. This is up by about 30% from 4 years prior, so there are changes happening across the country. When we worked to add fentanyl to the New York State formulary in 2007 we were met with great resistance by the regulators, who were concerned about the perception of loose controls on EMS and the high propensity for diversion of fentanyl. We made the case, and have a successful, although restrictive program in New York. In NY we have 18 regions, each with different protocols, but all approved by a State Bureau of Narcotics Enforcement, Bureau of EMS as well as Medical Advisory Council and EMS Council--an arduous process to change protocol and formulary, but possible. For now, study the problem, optimize pain management with morphine, and find the pathway that it takes to negotiate the way through the regulators. Dr. Galinski highlights a reasonable protocol for rapid titration of very small doses of morphine that may serve as a stepping stone for you.
>> I was convinced from my practice in EMS and in the ED that fentanyl was the best choice of prehospital opiate before I added the use of the mucosal atomizer to my skill set, and now I am even more convinced. Fentanyl intranasal is hands down the best way to management acute traumatic pain in children, and for adults, the rapid onset, short half-life, minimal histamine release and hemodynamic profile make it the all-round best agent. Dr. Galinski's study comparing F and M was small and had a non-significant trend toward better relief with F. More than anything else it, and work by others including Gallagher in the ED, have demonstrated that the best way to get relief of pain for our patients is to give those administering analgesia the latitude to give more if needed.
>> As Dr. Galinski says, the treatment must "be adapted to pain intensity, patient and pathology." Our providers have the skill to manage pain; we need to give them the tools they need to do it.
>> MD
>> Michael W. Dailey, MD FACEP >> Director of Prehospital Care and Education >> Associate Professor of Emergency Medicine >> Albany Medical Center >> 518/ 262-3773 >> ________________________________________ >> From: naemsp-dialog@googlegroups.com [naemsp-dialog@googlegroups.com] On Behalf Of Wegandy [wega...@aol.com] >> Sent: Saturday, September 18, 2010 23:02 >> To: naemsp-dialog@googlegroups.com >> Subject: Re: [NAEMSP Dialog] Prehospital Pain Management
>> One aspect that has not been discussed is restrictive state mandated protocols that limit a medical director's ability to choose appropriate analgesics for those paramedics working under her/his license.
>> For example, Arizona, USA, where I live, has very archaic and restrictive protocols which must be adhered to by all EMS services. Morphine is the only opioid allowed. Paramedics are not allowed to give fentanyl. Only nurses can give fentanyl in the field, which at least allows flight nurses to use it. AZ also has a system of base hospitals that mandates that every EMS service be tied to a base hospital. The base hospitals have what are called "prehospital coordinators" which are always nurses, most of which have never spent more than an hour or two in an ambulance. One of them said to me that "fentanyl has no place in EMS. Our ER doctors cannot even use it."
>> When one lives in a place like Arizona, it's useless to discuss choices in prehospital analgesia because there are none. And it's useless to discuss titration, because the state protocols do not mention it. They call for set doses, regardless of patient weight or other factors that might enter the minds of somebody who knew what s/he was doing.
>> As an EMS educator, I go beyond state protocols and teach my students the theories of pain management, but they will never be able to use them if they practice in Arizona.
>> I would be interested to know whether or not other states have such restrictive rules.
My comments are mostly non-clinical in nature since I get to work with the esteemed Dr. Kanowitz as our clinical guru.
I did have the opportunity to manage a medium size service in a large ski resort community that literally used fentanyl by bucket. Our protocol for pain management was a standing order for MS or fentanyl up to a limit, followed by a call-in if more was required. Through an unintended quirk of fate and politics, our protocols changed to "all standing order" concept and we really saw very little change in prehospital pain management. Generally, fentanyl doses stayed under 200mcg during scene calls without any reported troubles. MS remained our primary agent for inter-facility use due to it's longer half-life. The one observation I do have is that the all standing order situation was quite useful in actually increasing provider accountability which we did not anticipate.
Considering our quantity of use, particularly in the winter months, control was a major operational concern. For what is worth, our state allows for ambulance services to be categorized a mid-level providers for DEA purposes and my opinion was that our organization spent more time and effort on proper control procedures because the medical director AND our department were both listed on the DEA certificate.
Obviously our system was trauma heavy, so I can't recall any instances where our providers we're suspicious of drug seeking behavior and we had pretty much dispelled the surgeon's exam concern with the CT, MRI & ultrasound machines many years before. We were always disappointed that nitrous oxide was unavailable, but you have trouble getting a therapeutic concentration without hypoxia at higher elevations. Cheers.
Sean M. Caffrey, CMO, MBA, NREMTP System Development Coordinator EMTS Section Colorado Department of Public Health & Environment 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 Office (303) 692-2916 Cell (720) 383-0250 Fax (303) 691-7720 Sean.Caff...@state.co.us
(re-posted on behalf of Paul Simpson [to keep discussion within the
same thread]
Hi to all
Entonox (nitrous 50%/oxygen 50%) was used in NSW, Australia for many
year prior to being replaced in the late 1990s by methoxyflurane.
Entonox was logistically difficult, having to cart around a large
cylinder. It was safe and effective, but little was written about it
from a research perspective. Methoxyflurane is commonly used in
Australia…administered through a lightweight inhaler held by the
patient, it is effectively self-administered at sub-anaesthetic
concentrations, generally with good effect, particularly in kids. One
of its downfalls is that it has to be constantly inhaled in order to
firstly achieve, then maintain analgesia. It also requires constant
instruction so ensure consistent breathing through the mouth and not
the nose! All clinical levels can administer methoxyflurane, with
many community first responders also being able to do so after
completing short courses.
Regards
Paul Simpson
Paramedic Research Fellow/Intensive Care Paramedic,
Ambulance Research Institute
Ambulance Service of New South Wales
On Sep 21, 12:44 pm, Mic Gunderson <mic.gunder...@gmail.com> wrote:
> (Re-posted on behalf of Craig McMillan [to keep the discussion in the
> same thread])
> Entonox (50% nitrous 50% oxygen) is readily available in New Zealand
> and is the primary means of pain relief for BLS providers there. It is
> available in a wide variety of tank sizes with a demand regulator
> similar to a SCBA tank.
> In my experience it is a safe and effective form of pain relief for a
> wide variety of patients, the only issue is that the tanks need to be
> shaken prior to use as the gases tend to separate especially in cold
> weather.
> Craig McMillan
> Former Kiwi, current American
> Sent from my iPhone
(Re-posted on behalf of Charles Krin [to keep discussion within the
same thread])
And yet, Methoxyflurane has a slow onset/offset of effect, is a very
potent
anesthetic (with a MAC listed as around 0.2%), a high degree of
lipid
solubility, has to be consistently inhaled for proper effect, and
requires care
by the medic to insure proper use.
sounds to me like it was a step backwards in safety to accommodate a
step
forward in convenience for the ambulance operators.
ck
Charles S. Krin, DO (ret)
EMS writer and educator, former FP/EP
On Sep 22, 1:57 pm, Mic Gunderson <mic.gunder...@gmail.com> wrote:
> (re-posted on behalf of Paul Simpson [to keep discussion within the
> same thread]
> Hi to all
> Entonox (nitrous 50%/oxygen 50%) was used in NSW, Australia for many
> year prior to being replaced in the late 1990s by methoxyflurane.
> Entonox was logistically difficult, having to cart around a large
> cylinder. It was safe and effective, but little was written about it
> from a research perspective. Methoxyflurane is commonly used in
> Australia…administered through a lightweight inhaler held by the
> patient, it is effectively self-administered at sub-anaesthetic
> concentrations, generally with good effect, particularly in kids. One
> of its downfalls is that it has to be constantly inhaled in order to
> firstly achieve, then maintain analgesia. It also requires constant
> instruction so ensure consistent breathing through the mouth and not
> the nose! All clinical levels can administer methoxyflurane, with
> many community first responders also being able to do so after
> completing short courses.
> Regards
> Paul Simpson
> Paramedic Research Fellow/Intensive Care Paramedic,
> Ambulance Research Institute
> Ambulance Service of New South Wales
(Re-posted on behalf of Paul Simpson [to keep the discussion within
the same thread])
Hi to all,
I think Charles raises some interesting points. Certainly
methoxyflurane had its limitations as most analgesics do, but I would
suggest that it is not at all a step backwards as suggested. In
clinical practice, with constant inhalation, methoxy actually has a
very rapid onset of effect and upon ceasing inhalation has a quick
‘washout’. As presented in our recent publication in Prehospital
Emergency Care (Middleton et al 2010;14;439-447), provides effective
analgesia in almost 60% of adult patients with moderate to severe pain
to whom it is administered, with a mean reduction in patient reported
pain score of 3.2 points (VNRS). There are few safety issues with
methoxy in the sub-anaesthetic doses used for analgesia. Sedation is
rare. It has an excellent safety profile as an analgesic.
As previously mentioned though, it can be very frustrating getting
patients to comply with instruction. Entonox however was not a whole
lot different as a comparison. It had a slower onset, a faster loss
of effect, and still required patients to constantly inhale in order
to maintain the effect, and cart around a heavy cylinder. For
patients who have difficulty using the inhaler and maintaining
constant inhalation, the inhaler can be attached to a standard resus
mask (in much the same way Entonox was administered) providing a
better effect.
The use of methoxy in our service is declining as we recommend it for
mild pain only these days. We advocate opioid analgesia for moderate
and severe pain. All paramedics, except those still undertaking basic
induction training over their first three years, within our 2 tiered
ambulance service can provide opioid analgesia using either IV morph
or IN fent. So use of methoxy has really dropped off in recent times,
which is fine, as patients are getting the more effective opiate based
analgesia more often when they need it.
I agree that methoxy may not tick all the boxes as the ‘ideal’
prehospital analgesic, but it remains a very safe and reasonably
effective analgesic option that has a clear role amongst a multi-agent
approach to prehospital analgesia.
Have attached some refs for papers about methoxy to further stimulate
the discussion! As a first time participant in the forum, I am very
much enjoying the discussion!
Middleton PM. Simpson PM. Sinclair G. Dobbins TA. Math B. Bendall JC.
Effectiveness of morphine, fentanyl, and methoxyflurane in the
prehospital setting. <http://
ovidsp.tx.ovid.com.ezproxy1.library.usyd.edu.au/sp-3.2.2b/ovid...>
Prehospital Emergency Care. 14(4):439-47, 2010 Oct-Dec.
Babl FE, Jamison SR, Spicer M, Bernard S. Inhaled methoxyflurane as a
prehospital analgesic in children. Emergency Medicine Australasia
2006;18(4):404-10.
Buntine P, Thom O, Babl F, Bailey M, Bernard S. Prehospital analgesia
in adults using inhaled methoxyflurane. Emergency Medicine Australasia
2007;19(6):509-14.
Grindlay J. Babl FE. Review article: Efficacy and safety of
methoxyflurane analgesia in the emergency department and prehospital
setting. [Review] [57 refs] <http://
ovidsp.tx.ovid.com.ezproxy1.library.usyd.edu.au/sp-3.2.2b/ovid...>
Emergency Medicine Australasia. 21(1):4-11, 2009 Feb.
Regards
Paul Simpson
Paramedic Research Fellow/Intensive Care Paramedic,
Ambulance Research Institute
Ambulance Service of New South Wales
On Sep 22, 2:00 pm, Mic Gunderson <mic.gunder...@gmail.com> wrote:
> (Re-posted on behalf of Charles Krin [to keep discussion within the
> same thread])
> And yet, Methoxyflurane has a slow onset/offset of effect, is a very
> potent
> anesthetic (with a MAC listed as around 0.2%), a high degree of
> lipid
> solubility, has to be consistently inhaled for proper effect, and
> requires care
> by the medic to insure proper use.
> sounds to me like it was a step backwards in safety to accommodate a
> step
> forward in convenience for the ambulance operators.
> ck
> Charles S. Krin, DO (ret)
> EMS writer and educator, former FP/EP
Hi Nitrous oxide / oxygene 50/50 is a good and simple way for analgesia in prehospital setting. Its efficiency was proven in many studies but never in this situation and only for moderate pain. We do not know its efficiency for sever pain in association with morphine, for example.
Question: Who know the prevalence of pain during the mobilisation of a trauma patient in spite of analgesia? I mean that some spoke about fentanyl for the mobilisation of patient but there is probably not a pain relief in all patients. So How many patients are still painful in spite of analgesia with a narcotic, for example? Is there reference about that?
Thank you
Michel Galinski CNRD Centre National de Ressources de lutte contre la Douleur Hôpital Armand Trousseau 26, av Arnold Netter 75571 Paris Cédex 12
Tel : +33 144735426 Secrétariat: +33 144735421
----- Message d'origine ----- De: Mic Gunderson <mic.gunder...@gmail.com> Date: Mercredi, Septembre 22, 2010 7:57 pm Objet: [NAEMSP Dialog] Re: Prehospital Pain Management À: NAEMSP Dialog <naemsp-dialog@googlegroups.com>
> (re-posted on behalf of Paul Simpson [to keep discussion within the > same thread]
> Hi to all > Entonox (nitrous 50%/oxygen 50%) was used in NSW, Australia for many > year prior to being replaced in the late 1990s by methoxyflurane. > Entonox was logistically difficult, having to cart around a large > cylinder. It was safe and effective, but little was written about it > from a research perspective. Methoxyflurane is commonly used in > Australia…administered through a lightweight inhaler held by the > patient, it is effectively self-administered at sub-anaesthetic > concentrations, generally with good effect, particularly in kids. One > of its downfalls is that it has to be constantly inhaled in order to > firstly achieve, then maintain analgesia. It also requires constant > instruction so ensure consistent breathing through the mouth and not > the nose! All clinical levels can administer methoxyflurane, with > many community first responders also being able to do so after > completing short courses. > Regards > Paul Simpson > Paramedic Research Fellow/Intensive Care Paramedic, > Ambulance Research Institute > Ambulance Service of New South Wales
> On Sep 21, 12:44 pm, Mic Gunderson <mic.gunder...@gmail.com> wrote: > > (Re-posted on behalf of Craig McMillan [to keep the discussion in the > > same thread])
> > Entonox (50% nitrous 50% oxygen) is readily available in New Zealand > > and is the primary means of pain relief for BLS providers there. It > is > > available in a wide variety of tank sizes with a demand regulator > > similar to a SCBA tank. > > In my experience it is a safe and effective form of pain relief for > a > > wide variety of patients, the only issue is that the tanks need to be > > shaken prior to use as the gases tend to separate especially in cold > > weather. > > Craig McMillan > > Former Kiwi, current American > > Sent from my iPhone
> -- > You received this message because you are subscribed to the Google > Groups "NAEMSP Dialog" group. > To post to this group, send email to naemsp-dialog@googlegroups.com > To unsubscribe from this group, send email to > naemsp-dialog+unsubscribe@googlegroups.com > For more options, visit this group at > http://groups.google.com/group/naemsp-dialog?hl=en > Visit NAEMSP at http://www.naemsp.org.
On Sep 22, 2:26 pm, galinski m <m.galin...@trs.aphp.fr> wrote:
> Hi
> Nitrous oxide / oxygene 50/50 is a good and simple way for analgesia in prehospital setting. Its efficiency was proven in many studies but never in this situation and only for moderate pain. We do not know its efficiency for sever pain in association with morphine, for example.
> Question: Who know the prevalence of pain during the mobilisation of a trauma patient in spite of analgesia? I mean that some spoke about fentanyl for the mobilisation of patient but there is probably not a pain relief in all patients. So How many patients are still painful in spite of analgesia with a narcotic, for example? Is there reference about that?
Dr. Galinski,
That is going to depend on a lot of things. Some people are more
responsive to opioids than others. The type of pain also matters. The
dose will have a significant effect. I remember reading that the range
of effective doses is very large. Comparing the effective dose at the
lowest end with the highest end, for opioid naive patients,k the high
end is ten times higher than the low end. this study does nothing to
contradict that. Unfortunately, I do not remember the source of that
range.
One study looked at a single 0.1 mg.kg dose of morphine. This study of
severe acute pain used a 50% decrease in the pain level as an
indication of adequate pain management.
Only 67% of patients had their pain decrease by at least half.
A 67% failure rate!
That is with a single 0.1mg/kg morphine dose. With the typical, at
least in America, ordered doses of 2 mg morphine, or even 5 mg
morphine, few patients are even approaching 0.1 mg/kg morphine. For an
80 kg patient (176 pounds), 2 mg is one quarter of this dose, that the
authors found to be inadequate. 5 mg is just a bit more than half of
the inadequate dose. Other studies have had similar results.
I discussed this study at length in a post on my blog.
Intravenous morphine at 0.1 mg/kg is not effective for controlling
severe acute pain in the majority of patients.
Bijur PE, Kenny MK, Gallagher EJ.
Ann Emerg Med. 2005 Oct;46(4):362-7.
PMID: 16187470 [PubMed - indexed for MEDLINE]
I sent a copy of the study to Mic to post.
The podcast of Dr. Edward Gentile talking about the very aggressive
morphine protocol used in his hospital without problems is at -
Titration is the only appropriate way to manage pain. Either side
effects prevent titration from continuing to the point of adequate
relief of pain, or the patient experiences adequate relief of pain.
Titration should not have any maximum dose. What would be the point?
With 0.1 mg/kg as a starting dose, rather than a total dose, the
pathetic 67% failure rate would be much, much lower.
> Michel Galinski
> CNRD
> Centre National de Ressources de lutte contre la Douleur
> Hôpital Armand Trousseau
> 26, av Arnold Netter
> 75571 Paris Cédex 12
> Tel : +33 144735426
> Secrétariat: +33 144735421
Thanks for sending me the PDF of that article and several others. I
have most of them now indexed and upload onto the resource page for
this topic (http://groups.google.com/group/naemsp-dialog/web/topic-4--- prehospital-pain-management). Here is what's available for download as
PDFs so far:
- Alonso-Serra H, Wesley K: NAEMSP Position Paper - Prehospital Pain
Management. Prehosp Emerg Care 2003; 7:482-488.
- Bijur PE, Kenny MK. Gallagher EJ: Intravenous Morphine at 0.1 mg/kg
Is Not Effective for Controlling Severe Acute Pain In the Majority of
Patients. Ann Emerg Med 2005; 46:362-367.
- Braude D, Richards M: Appeal for Fentanyl Prehospital Use (Letter to
the Editor). Prehosp Emerg Care 2004; 8:441-442.
- Galinski M, et al: Out-of-hospital emergency medicine in pediatric
patients: prevalence and management of pain. 2010 Am J Emerg Med
(article in press).
- Galinski M, Ruscev M, Gonzalez G, et al: Prevalence and Management
of Acute Pain in Prehos[pital Emergency Medicine. Prehosp Emerg Care
2010;14:334–339.
- Kanowitz A, Dunn TM, Kanowitz EM, et al: Safety and Effectiveness of
Fentanyl Administration for Prehospital Pain Management. Prehosp Emerg
Med 2006; 1-7.
- Middleton PM, Simpson PM, Sinclair G, Dobbins TA, Bendall JC:
Effectiveness of Morphone, Fentanyl, and Methoxyflurance in the
Prehospital Setting. Prehosp Emerg Med 2010;14:439–447.
- Rupp T, Delaney KA: Inadequate Analgesia in Emergency Medicine. Ann
Emerg Med 2004;43:494-503.
- Shavit I, Hirshman E: Management of Children Undergoing Painful
Procedures in the Emergency Department by Non-Anesthesiologists.
Israel Med Assn J 2004; 6:350-355.
- Svenson JE, Abernathy MK: Ketamine for prehospital use: new look at
an old drug. Am J Emerg Med (2007) 25, 977–980.
- Veysman BD: Truth Hurts. Acad Emerg Med 2009.
If anyone has other articles that would be useful to add to this
collection for the reference of those interested in reading more about
this topic, please send them to me at mic.gunder...@gmail.com.
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
> 1. CDC MMWR report (59:32 1026) "The number of poisoning deaths from
> opiates (1997=4000 deaths 2007=14,500 deaths)"
> 2. CDC MMWR report (59 (30);957 Death Rates for the three leading
> causes of Injury Death" in which deaths from MVA and firearms has
> dropped but death from drugs is on exponential rise.
(Re-posted on behalf of Gene Gandy [to keep the discussion in the same
thread])
Query: Can methox be used in conjunction with opioid analgesics? For
example, let's say that the methox doesn't quite do the job. Can you
add in some fentanyl? Any problems with that? Could you use lower
doses of fentanyl if you paired it with methox?
Gene
(Gene Gandy, Tucson, AZ)
(Re-posted on behalf of Jason Bendall [to keep the discussion in the
same thread])
Hi Jason Bendall here from the Ambulance Research Institute in Sydney.
In our recent publication (Prehospital Emergency Care 2010;14;439-447)
there was no compelling evidence that combinations were more effective
than morphine alone. Our service has used methoxy, morphine and IN
fentanyl alone or in combination for some time. Based on our results
we encourage our paramedics to use morphine as first line for
moderate / severe pain as it appears the most effective option. That
being said, methoxy is an effective agent in its own right. In answer
to your question though, there is no issue with giving methoxy and if
inadequate giving an opioid. I am of the view however that if
possible, give morphine initially as it is associated with much higher
odds of effective analgesia.
Dr Jason Bendall
MBBS MM(ClinEpi) PhD FACAP
Intensive Care Paramedic
On Sep 24, 9:09 am, Mic Gunderson <mic.gunder...@gmail.com> wrote:
> (Re-posted on behalf of Gene Gandy [to keep the discussion in the same
> thread])
> Query: Can methox be used in conjunction with opioid analgesics? For
> example, let's say that the methox doesn't quite do the job. Can you
> add in some fentanyl? Any problems with that? Could you use lower
> doses of fentanyl if you paired it with methox?
> Gene
> (Gene Gandy, Tucson, AZ)
> (Re-posted on behalf of Jason Bendall [to keep the discussion in the
> same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney.
> In our recent publication (Prehospital Emergency Care 2010;14;439-447)
> there was no compelling evidence that combinations were more effective
> than morphine alone. Our service has used methoxy, morphine and IN
> fentanyl alone or in combination for some time. Based on our results
> we encourage our paramedics to use morphine as first line for
> moderate / severe pain as it appears the most effective option. That
> being said, methoxy is an effective agent in its own right. In answer
> to your question though, there is no issue with giving methoxy and if
> inadequate giving an opioid. I am of the view however that if
> possible, give morphine initially as it is associated with much higher
> odds of effective analgesia.
> Dr Jason Bendall
> MBBS MM(ClinEpi) PhD FACAP
> Intensive Care Paramedic
Hi Charles, to be honest we only looked at records from a database so did not look at this issue specifically case by case (almost 13,000 patients given morphine). Our Jurisdiction has however used morphine for over 30 years and are unaware of any significant issues. Our jurisdiction gives thousands of patients morphine annually. Over my 15 years with ASNSW it has not cropped up that often. In saying that I have had some patients with localised erythema post administration of morphine.
(Re-posted an behalf of Charles Krin [to keep the discussion in the
same thread])
Jason:
In your study, did you notice a problem with histamine release or
other
forms of morphine intolerance?
ck
(Charles S. Krin, DO, retired FP, ED and EMS physician)
On Sep 24, 9:12 am, Mic Gunderson <mic.gunder...@gmail.com> wrote:
> (Re-posted on behalf of Jason Bendall [to keep the discussion in the
> same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney.
> In our recent publication (Prehospital Emergency Care 2010;14;439-447)
> there was no compelling evidence that combinations were more effective
> than morphine alone. Our service has used methoxy, morphine and IN
> fentanyl alone or in combination for some time. Based on our results
> we encourage our paramedics to use morphine as first line for
> moderate / severe pain as it appears the most effective option. That
> being said, methoxy is an effective agent in its own right. In answer
> to your question though, there is no issue with giving methoxy and if
> inadequate giving an opioid. I am of the view however that if
> possible, give morphine initially as it is associated with much higher
> odds of effective analgesia.
> Dr Jason Bendall
> MBBS MM(ClinEpi) PhD FACAP
> Intensive Care Paramedic
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Thank you. I'm quite surprised, and it may be due to some genetic variation. Anecdotally, I saw significant histamine symptoms in almost 15% of the patients that I treated during my career. A small percentage, like my ex wife, had a severe, anaphylactoid type reaction. including swelling of the face and tongue, generalized wheal and flare, and occasionally wheezing.
Then again, in that same patient population (Louisiana, 1988-2005), it was not unusual to have significant problems with sphincter of Oddi 'squeeze' due to morphine, resulting in an increase in gall bladder symptoms.
ck Charles S. Krin, DO Retired FP/EP/EMS physician, educator and author.
In a message dated 09/24/10 09:33:14 Central Daylight Time,
Hi Charles, to be honest we only looked at records from a database so did not look at this issue specifically case by case (almost 13,000 patients given morphine). Our Jurisdiction has however used morphine for over 30 years and are unaware of any significant issues. Our jurisdiction gives thousands of patients morphine annually. Over my 15 years with ASNSW it has not cropped up that often. In saying that I have had some patients with localised erythema post administration of morphine.
(Re-posted an behalf of Charles Krin [to keep the discussion in the same thread])
Jason:
In your study, did you notice a problem with histamine release or other forms of morphine intolerance?
ck
(Charles S. Krin, DO, retired FP, ED and EMS physician)
On Sep 24, 9:12 am, Mic Gunderson <mic.gunder...@gmail.com> wrote: > (Re-posted on behalf of Jason Bendall [to keep the discussion in the > same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney. > In our recent publication (Prehospital Emergency Care 2010;14;439-447) > there was no compelling evidence that combinations were more effective > than morphine alone. Our service has used methoxy, morphine and IN > fentanyl alone or in combination for some time. Based on our results > we encourage our paramedics to use morphine as first line for > moderate / severe pain as it appears the most effective option. That > being said, methoxy is an effective agent in its own right. In answer > to your question though, there is no issue with giving methoxy and if > inadequate giving an opioid. I am of the view however that if > possible, give morphine initially as it is associated with much higher > odds of effective analgesia. > Dr Jason Bendall > MBBS MM(ClinEpi) PhD FACAP > Intensive Care Paramedic
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--------------------------------------------- Confidentiality Notice: The information in this message is intended for the named recipients only. It may contain privileged and confidential information. If you are not the intended recipient, you must not copy, distribute, take any action in reliance on it or disclose any details of this message to any other person or organisation. If you have received this message in error, please delete this copy.
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May I add in this: In patients with renal insufficiency or chronic renal failure Stage II or III, morphine carries some cautions. While at one time it was thought that morphine levels accumulated in patients with renal insufficiency, now it has been shown that it's metabolite, Morphine-6-glucuronide (M6G), if I understand it correctly, is the agent that accumulates in renal-impaired patients. That metabolite, if I understand correctly, has significant mu receptor blocking powers and can also depress respiratory depression. Therefore, I am told that MS should be administered with caution to patients in renal failure, OR, the doses should be reduced significantly. There seem to be a plethora of studies out there, all of which will pop up with a Google for "morphine metabolites."
Not being a pharmacist nor a chemist, I run the risk of misunderstanding what I'm reading sometimes, but my reading seems to tell me that fentenyl or alfentanyl are the analgesics of choice for patients with renal insufficiency.
Fentanyl seems to have neither the histamine release problems nor the metabolite build-up problems of morphine.
Can anyone comment on this? Is there any significant risk in choosing one over the other in prehospital care given generally short scene to hospital transport times?
-----Original Message----- From: Mic Gunderson <mic.gunder...@gmail.com> To: NAEMSP Dialog <naemsp-dialog@googlegroups.com> Sent: Fri, Sep 24, 2010 6:17 am Subject: [NAEMSP Dialog] Re: Prehospital Pain Management
(Re-posted an behalf of Charles Krin [to keep the discussion in the same thread])
Jason:
In your study, did you notice a problem with histamine release or other forms of morphine intolerance?
ck
(Charles S. Krin, DO, retired FP, ED and EMS physician)
On Sep 24, 9:12 am, Mic Gunderson <mic.gunder...@gmail.com> wrote: > (Re-posted on behalf of Jason Bendall [to keep the discussion in the > same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney. > In our recent publication (Prehospital Emergency Care 2010;14;439-447) > there was no compelling evidence that combinations were more effective > than morphine alone. Our service has used methoxy, morphine and IN > fentanyl alone or in combination for some time. Based on our results > we encourage our paramedics to use morphine as first line for > moderate / severe pain as it appears the most effective option. That > being said, methoxy is an effective agent in its own right. In answer > to your question though, there is no issue with giving methoxy and if > inadequate giving an opioid. I am of the view however that if > possible, give morphine initially as it is associated with much higher > odds of effective analgesia. > Dr Jason Bendall > MBBS MM(ClinEpi) PhD FACAP > Intensive Care Paramedic
-- You received this message because you are subscribed to the Google Groups "NAEMSP Dialog" group. To post to this group, send email to naemsp-dialog@googlegroups.com To unsubscribe from this group, send email to naemsp-dialog+unsubscribe@googlegroups.com For more options, visit this group at http://groups.google.com/group/naemsp-dialog?hl=en Visit NAEMSP at http://www.naemsp.org.
Thank you. I'm quite surprised, and it may be due to some genetic variation. Anecdotally, I saw significant histamine symptoms in almost 15% of the patients that I treated during my career. A small percentage, like my ex wife, had a severe, anaphylactoid type reaction. including swelling of the face and tongue, generalized wheal and flare, and occasionally wheezing.
Then again, in that same patient population (Louisiana, 1988-2005), it was not unusual to have significant problems with sphincter of Oddi 'squeeze' due to morphine, resulting in an increase in gall bladder symptoms.
ck Charles S. Krin, DO Retired FP/EP/EMS physician, educator and author.
In a message dated 09/24/10 09:33:14 Central Daylight Time, JBend...@ambulance.nsw.gov.au writes:
Hi Charles, to be honest we only looked at records from a database so did not look at this issue specifically case by case (almost 13,000 patients given morphine). Our Jurisdiction has however used morphine for over 30 years and are unaware of any significant issues. Our jurisdiction gives thousands of patients morphine annually. Over my 15 years with ASNSW it has not cropped up that often. In saying that I have had some patients with localised erythema post administration of morphine.
(Re-posted an behalf of Charles Krin [to keep the discussion in the same thread])
Jason:
In your study, did you notice a problem with histamine release or other forms of morphine intolerance?
ck
(Charles S. Krin, DO, retired FP, ED and EMS physician)
On Sep 24, 9:12 am, Mic Gunderson <mic.gunder...@gmail.com> wrote: > (Re-posted on behalf of Jason Bendall [to keep the discussion in the > same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney. > In our recent publication (Prehospital Emergency Care 2010;14;439-447) > there was no compelling evidence that combinations were more effective > than morphine alone. Our service has used methoxy, morphine and IN > fentanyl alone or in combination for some time. Based on our results > we encourage our paramedics to use morphine as first line for > moderate / severe pain as it appears the most effective option. That > being said, methoxy is an effective agent in its own right. In answer > to your question though, there is no issue with giving methoxy and if > inadequate giving an opioid. I am of the view however that if > possible, give morphine initially as it is associated with much higher > odds of effective analgesia. > Dr Jason Bendall > MBBS MM(ClinEpi) PhD FACAP > Intensive Care Paramedic
-- You received this message because you are subscribed to the Google Groups "NAEMSP Dialog" group. To post to this group, send email to naemsp-dialog@googlegroups.com To unsubscribe from this group, send email to naemsp-dialog+unsubscribe@googlegroups.com For more options, visit this group at http://groups.google.com/group/naemsp-dialog?hl=en Visit NAEMSP at http://www.naemsp.org.
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Gene: to the best of my (off the cuff) knowledge, that problem is specific to morphine, and is probably related to the known problems with histamine release and morphine.
ck Charles S. Krin, DO Retired FP/EP/EMS physician, educator and author
In a message dated 09/26/10 06:22:11 Central Daylight Time, wega...@aol.com
writes:
Dr. K,
Would fentanyl produce the same problems with the S of O?
Thank you. I'm quite surprised, and it may be due to some genetic variation. Anecdotally, I saw significant histamine symptoms in almost 15% of the patients that I treated during my career. A small percentage, like my ex wife, had a severe, anaphylactoid type reaction. including swelling of the face and tongue, generalized wheal and flare, and occasionally wheezing.
Then again, in that same patient population (Louisiana, 1988-2005), it was not unusual to have significant problems with sphincter of Oddi 'squeeze' due to morphine, resulting in an increase in gall bladder symptoms.
ck Charles S. Krin, DO Retired FP/EP/EMS physician, educator and author.
In a message dated 09/24/10 09:33:14 Central Daylight Time, _JBend...@ambulance.nsw.gov.au_ (mailto:JBend...@ambulance.nsw.gov.au) writes:
Hi Charles, to be honest we only looked at records from a database so did not look at this issue specifically case by case (almost 13,000 patients given morphine). Our Jurisdiction has however used morphine for over 30 years and are unaware of any significant issues. Our jurisdiction gives thousands of patients morphine annually. Over my 15 years with ASNSW it has not cropped up that often. In saying that I have had some patients with localised erythema post administration of morphine.
(mailto:mic.gunder...@gmail.com) > wrote: > (Re-posted on behalf of Jason Bendall [to keep the discussion in the > same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney. > In our recent publication (Prehospital Emergency Care 2010;14;439-447) > there was no compelling evidence that combinations were more effective > than morphine alone. Our service has used methoxy, morphine and IN > fentanyl alone or in combination for some time. Based on our results > we encourage our paramedics to use morphine as first line for > moderate / severe pain as it appears the most effective option. That > being said, methoxy is an effective agent in its own right. In answer > to your question though, there is no issue with giving methoxy and if > inadequate giving an opioid. I am of the view however that if > possible, give morphine initially as it is associated with much higher > odds of effective analgesia. > Dr Jason Bendall > MBBS MM(ClinEpi) PhD FACAP > Intensive Care Paramedic
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I think the best answer is weight based or reasonably developed protocols of titrated doses of narcotics will rarely lead to complications. Can they--sure. M6G is an active metabolite, and as such will be causing the effects you are seeking; therefore titrated doses of morphine will be fine. Demerol is another story, where normeperidine is a metabolite that does not have analgesic properrties and will cause seizures at high levels.
I think we are rapidly arriving at two main threads here. First, how do we get people to use medications for patients with pain? And second, what are the optimal agents and treatment regimens. I wish I had an answer to the first, and hope to learn from others. For the second, I believe we need a medication that can be titrated rapidly to reasonable analgesic effect, and fentanyl, 1 mcg/kg, followed by 0.5 mcg/kg repeated in 5 minute intervals seems to be the best narcotic option.
Michael
ps: One other thought: in accordance with recommendations for safe documentation practices, can we please refer to morphine as "morphine" and not MS? It's an old trap we all fall into from time to time.
Michael W. Dailey, MD FACEP
Director of Prehospital Care and Education
Associate Professor of Emergency Medicine
Albany Medical Center
518/ 262-3773
________________________________________
From: naemsp-dialog@googlegroups.com [naemsp-dialog@googlegroups.com] On Behalf Of Wegandy [wega...@aol.com]
Sent: Sunday, September 26, 2010 0:23
To: naemsp-dialog@googlegroups.com
Subject: Re: [NAEMSP Dialog] Re: Prehospital Pain Management
May I add in this: In patients with renal insufficiency or chronic renal failure Stage II or III, morphine carries some cautions. While at one time it was thought that morphine levels accumulated in patients with renal insufficiency, now it has been shown that it's metabolite, Morphine-6-glucuronide (M6G), if I understand it correctly, is the agent that accumulates in renal-impaired patients. That metabolite, if I understand correctly, has significant mu receptor blocking powers and can also depress respiratory depression. Therefore, I am told that MS should be administered with caution to patients in renal failure, OR, the doses should be reduced significantly. There seem to be a plethora of studies out there, all of which will pop up with a Google for "morphine metabolites."
Not being a pharmacist nor a chemist, I run the risk of misunderstanding what I'm reading sometimes, but my reading seems to tell me that fentenyl or alfentanyl are the analgesics of choice for patients with renal insufficiency.
Fentanyl seems to have neither the histamine release problems nor the metabolite build-up problems of morphine.
Can anyone comment on this? Is there any significant risk in choosing one over the other in prehospital care given generally short scene to hospital transport times?
-----Original Message-----
From: Mic Gunderson <mic.gunder...@gmail.com>
To: NAEMSP Dialog <naemsp-dialog@googlegroups.com>
Sent: Fri, Sep 24, 2010 6:17 am
Subject: [NAEMSP Dialog] Re: Prehospital Pain Management
(Re-posted an behalf of Charles Krin [to keep the discussion in the
same thread])
Jason:
In your study, did you notice a problem with histamine release or
other
forms of morphine intolerance?
ck
(Charles S. Krin, DO, retired FP, ED and EMS physician)
On Sep 24, 9:12 am, Mic Gunderson <mic.gunder...@gmail.com<mailto:mic.gunder...@gmail.com>> wrote:
> (Re-posted on behalf of Jason Bendall [to keep the discussion in the
> same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney.
> In our recent publication (Prehospital Emergency Care 2010;14;439-447)
> there was no compelling evidence that combinations were more effective
> than morphine alone. Our service has used methoxy, morphine and IN
> fentanyl alone or in combination for some time. Based on our results
> we encourage our paramedics to use morphine as first line for
> moderate / severe pain as it appears the most effective option. That
> being said, methoxy is an effective agent in its own right. In answer
> to your question though, there is no issue with giving methoxy and if
> inadequate giving an opioid. I am of the view however that if
> possible, give morphine initially as it is associated with much higher
> odds of effective analgesia.
> Dr Jason Bendall
> MBBS MM(ClinEpi) PhD FACAP
> Intensive Care Paramedic
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(Re-posted on behalf of Gene Gandy [to keep discussion in same
thread])
Here in the US I suggest that we in prehospital care now tend to find
that fentanyl is better at achieving effective analgesia in the short
run than morphine, and so many EMS services now carry both morphine
and fentanyl. Fentanyl is used for skeletal injury pain and visceral
pain, and MS for cardiac pain, CHF, and so forth, although there are
discussions going on about whether or not morphine has any real
advantages other than length of effect. I like fentanyl because I can
give it to a hip fracture patient a couple of minutes after I arrive,
and in 5 minutes, she'll be pain free enough for me to be able to move
her without subjecting her to excruciating pain. MS would take three
times as long.
So I'm wondering what the thinking is in Australia about morphine vs.
fentanyl?
Also, here, some services are now carrying hydromorphone (Dilaudid).
Any thoughts about that?
It's of great interest to me how we come to different conclusions
about choice of drugs depending where in the world we are.
A appreciate your response and your thoughts.
Gene Gandy
On Sep 24, 9:12 am, Mic Gunderson <mic.gunder...@gmail.com> wrote:
> (Re-posted on behalf of Jason Bendall [to keep the discussion in the
> same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney.
> In our recent publication (Prehospital Emergency Care 2010;14;439-447)
> there was no compelling evidence that combinations were more effective
> than morphine alone. Our service has used methoxy, morphine and IN
> fentanyl alone or in combination for some time. Based on our results
> we encourage our paramedics to use morphine as first line for
> moderate / severe pain as it appears the most effective option. That
> being said, methoxy is an effective agent in its own right. In answer
> to your question though, there is no issue with giving methoxy and if
> inadequate giving an opioid. I am of the view however that if
> possible, give morphine initially as it is associated with much higher
> odds of effective analgesia.
> Dr Jason Bendall
> MBBS MM(ClinEpi) PhD FACAP
> Intensive Care Paramedic
(Posted on behalf or Derek Isenberg [Signature file added below post])
We should also mention that fentanyl can be given intransasally, which
is
great for the pediatric population. A quick spray can relieve pain
without
the discomfort of an IV.
A* randomized controlled trial of intranasal fentanyl vs intravenous
morphine for analgesia in the prehospital setting *
(Derek Isenberg, MD, NREMT-P
Medical Director
Mercy EMS
Mercy Catholic Medical Center
Department of Emergency Medicine
501 South 54th Street
Philadelphia, PA 19143
215.748.9740
215.748.9208 (fax))
Hi About Fentanyl, We can not say that fentanyl is better than morphine. There is not study to confirm that. There is currently 2 published studies in prehospital setting (fenta vs morphine (2005) ; sufenta vs morphine (2010)). The last one (in press) compared morphine and sufentanil (titrated, IV) in trauma patients in prehospital setting. This study showed that the rate of relief patient was better only one time, at 9 minutes after injection in sufentanil group. But 3, 6, 12 and 15 minutes there was no difference. However morphine was better in the next hours (6 hours follow up). Bounes et al Ann Emerg Med 2010 (in press).
Kind regards
Michel Galinski
Centre National de Ressources de lutte contre la Douleur - CNRD. H pital Armand Trousseau 26, av Arnold Netter 75571 Paris cedex 12 Secretariat: 01 44 73 54 21 Site internet: www.cnrd.fr
-----Message d'origine----- De : naemsp-dialog@googlegroups.com [mailto:naemsp-dialog@googlegroups.com]De la part de Mic Gunderson Envoy : mar. 28 septembre 2010 03:46 : NAEMSP Dialog Objet : [NAEMSP Dialog] Re: Prehospital Pain Management
(Re-posted on behalf of Gene Gandy [to keep discussion in same thread])
Here in the US I suggest that we in prehospital care now tend to find that fentanyl is better at achieving effective analgesia in the short run than morphine, and so many EMS services now carry both morphine and fentanyl. Fentanyl is used for skeletal injury pain and visceral pain, and MS for cardiac pain, CHF, and so forth, although there are discussions going on about whether or not morphine has any real advantages other than length of effect. I like fentanyl because I can give it to a hip fracture patient a couple of minutes after I arrive, and in 5 minutes, she'll be pain free enough for me to be able to move her without subjecting her to excruciating pain. MS would take three times as long. So I'm wondering what the thinking is in Australia about morphine vs. fentanyl? Also, here, some services are now carrying hydromorphone (Dilaudid). Any thoughts about that? It's of great interest to me how we come to different conclusions about choice of drugs depending where in the world we are. A appreciate your response and your thoughts. Gene Gandy
On Sep 24, 9:12 am, Mic Gunderson <mic.gunder...@gmail.com> wrote:
> (Re-posted on behalf of Jason Bendall [to keep the discussion in the > same thread])
> Hi Jason Bendall here from the Ambulance Research Institute in Sydney. > In our recent publication (Prehospital Emergency Care 2010;14;439-447) > there was no compelling evidence that combinations were more effective > than morphine alone. Our service has used methoxy, morphine and IN > fentanyl alone or in combination for some time. Based on our results > we encourage our paramedics to use morphine as first line for > moderate / severe pain as it appears the most effective option. That > being said, methoxy is an effective agent in its own right. In answer > to your question though, there is no issue with giving methoxy and if > inadequate giving an opioid. I am of the view however that if > possible, give morphine initially as it is associated with much higher > odds of effective analgesia. > Dr Jason Bendall > MBBS MM(ClinEpi) PhD FACAP > Intensive Care Paramedic
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Hi Paul, yes this is a subject that interests me - from a clinical
reasoning aspect and also from a attitudinal perspective. There is
limited research into paramedic attittudes towards analgesia - Jones &
Machen 2003; Hennes, Kim & Pirrallo 2005 are a couple that spring to
mind that explored this somewhat. I think that there is a lack of
education about pain theory - physiology, patient-focused assessment
of pain, and appropriate pain management. It is unfortunate that many
services have limited pain management options, further 'boxing'
paramedics thinking towards the management of pain.
I'm looking foward to reading the rest of this discussion!
Sarah
On Sep 15, 11:43 am, "SIMPSON, Paul" <PSIMP...@ambulance.nsw.gov.au>
wrote:
> Thankyou for the opportunity to participate in the forum. Being new
> to this forum, this seems to me to be a great initiative. The ideas outlined to date will make for interesting discussion. I would also like to see the qualitative aspects of pain management discussed over the coming weeks, with regard to paramedic decisions about how legitimate a patient’s stated pain really is. We use a verbal numeric rating scale in our Australian service, but anecdote suggests that our paras have little faith in the patient’s reported pain score and this important field is absent on patient care records in almost half of cases involving analgesia administration. So if we are not using pain scores, what are we basing our assessment of pain on and what is underpinning our decision to provide analgesia or not, and how much? As mentioned previously by another forum participant, is getting a pain score really the way to go?
> Looking forward to chatting further.
> Paul Simpson
> Paramedic Research Fellow/Intensive Care Paramedic,
In New Zealand, we have used 50% nitrous oxide / 50% oxygen (Entonox)
for many years with good effect. In 2007 we introduced methoxyflurane,
but in some areas the economics of using methoxyflurane has meant that
Entonox has replaced methoxyflurane... Our procedures (which have a
good amount of latitude in them) indicate Entonox for mild-moderate
pain. Entonox is safe to use, the cylinder can be last more than one
patient, and patients acheive good short term relief - if properly
instructed in the use, have an adequate tidal volume for inhalation,
and the patient has the ability to comprehend and self-administer.
Methoxyflurane is indicated in our procedures for moderate to severe
pain. Both can be administered at BLS level, hopefully meaning that
our patients get short-term analgesia, with the option of ILS / ALS
backup for parenteral analgesia (we have morphine, ketamine and
midazolam available for use).
Sarah Werner
CEU Tutor, Advanced Paramedic
St John, New Zealand
On Sep 21, 7:54 am, Mic Gunderson <mic.gunder...@gmail.com> wrote:
> What are the pain management options for BLS services? Or, from a
> policy development perspective, what SHOULD the options be for a BLS
> service?
> This brings to mind the various non-pharmacologic methods that you and
> others have mentioned in earlier posts. Should these non-pharmacologic
> methods get more attention even from ALS providers? I'm thinking about
> cold packs, positioning, transcutaneous electronic nerve stimulators
> (TENS), audio analgesia, guided imagery, etc.
> I'm also wondering what the feelings are from the group for use of 50%
> nitrous oxide / 50% oxygen mixtures by BLS crews (assuming appropriate
> protocols and training).
> On Sep 20, 2:04 pm, Keith Wesley <drwes...@charter.net> wrote:
> > Dr. Isenberg's question is vital. Do you have policy for which patients go ALS vs. BLS? I do and need for perenteral pain management is ALS.
> > Keith Wesley, MD
> > Medical Director
> > HealthEast Medical Transportation
> > St. Paul, MN
> > On Sep 19, 2010, at 8:55 PM, Derek Isenberg wrote:
> > > One issue that I have not been able to resolve is that in tiered EMS systems, patients that may need analgesia are triaged to BLS
> > > units. For example, the fall with arm/hip fracture or headache may be triaged to BLS providers.
> > > How do we reconcile this?
> > > Derek Isenberg, MD, NREMT-P
> > > Medical Director
> > > Mercy EMS
> > > Mercy Catholic Medical Center
> > > Department of Emergency Medicine
> > > 501 South 54th Street
> > > Philadelphia, PA 19143
> > > 215.748.9740
> > > 215.748.9208 (fax)- Hide quoted text -
The discussion has gotten quiet and we have had the the topic open for
over a month now, so I'm going to ask if any of our invited
participants or others have any closing remarks or summations , to
please post them today or tomorrow.
Thanks,
--- Mic
Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS
