What are some of the open questions that need to be answered through
research or policy development related to prehospital pain management? What
controversies are out there that need to be explored? What else should we
address during this conversation over the next few weeks?
I'll first ask this of the invited participants and will then open it up to
all shortly.
Looking forward to this important topic.
Dr Koehler
Alaska
-----Original Message-----
From: naemsp...@googlegroups.com
[mailto:naemsp...@googlegroups.com] On Behalf Of Mic Gunderson
Sent: Wednesday, September 08, 2010 4:48 AM
To: NAEMSP Dialog
Thanks,
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Margaret A. Keavney
Hello to all,
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,
Ambulance Research Institute
Ambulance Service of New South Wales, Australia
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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.gu...@gmail.com>
Date: Mercredi, Septembre 15, 2010 10:19 pm
Objet: [NAEMSP Dialog] Re: Prehospital Pain Management
À: NAEMSP Dialog <naemsp...@googlegroups.com>
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 here was not improvement of pain relief neither reduction of morphine side effects (galinski Am j Emerg Med 2007).
ketamine is not exactly an antalgic drug,; it is an antihyperalgesic drug and sedative drug.
Ketamine can be use doses of 0.5 to 1 mg/kg IV, but it is more a sedative action.
2 to 3mg/kg IV are anesthesiologic doses.
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 here was not improvement of pain relief neither reduction of morphine side effects (galinski Am j Emerg Med 2007). ketamine is not exactly an antalgic drug,; it is an antihyperalgesic drug and sedative drug. Ketamine can be use doses of 0.5 to 1 mg/kg IV, but it is more a sedative action. 2 to 3mg/kg IV are anesthesiologic doses. 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 -- You received this message because you are subscribed to the Google Groups "NAEMSP Dialog" group. To post to this group, send email to naemsp...@googlegroups.com
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)
Gene,
I read your post with great interest and dismay. As the State Medical Director for Colorado, it is hard for me to understand how statewide mandates get passed that are so restrictive that they negatively affect patient care. How can a prehospital provider possibly provide adequate care with only one opioid choice? What do they do when a patient requires pain management and the patient is allergic to morphine? Pain is too prevalent of a complaint in EMS to not give paramedics appropriate tools to manage. A single opioid is simply inadequate and not providing early pain management is simply poor patient care.
Fentanyl is such a safe and effective medication available for field use that I almost cannot believe that any EMS agency would function without it in their toolbox. I had the good fortune of being involved with a very progressive private ambulance service (Pridemark Paramedics) from 1999 – 2005. During that time we were able to complete a fairly extensive study of prehospital pain management and the use of fentanyl and morphine. From the study data we published an article that dealt with the safety and efficacy of fentanyl in over 2100 patients (PREHOSPITAL EMERGENCY CARE 2006;10:1–7). We had plans to also publish some of that comparative data (morphine vs fentanyl) but unfortunately I left Pridemark prior to completing that part of the study. However, fentanyl is clearly a safe and very effective opioid available for prehospital use.
Please feel free to share the article published in Prehosital Emergency Care with the appropriate powers in Arizona. If I can be of any help I would be happy to personally share my perspective as well as the data from our study and what we learned.
I have included the abstract below.
Arthur Kanowitz MD FACEP
State Medical Director
Emergency Medical and Trauma Services Section
Health Facilities and Emergency Medical Services Division
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver. Colorado 80246-1530
office 303 692-2984
mobile 720 641-3540
SAFETY AND EFFECTIVENESS OF FENTANYL ADMINISTRATION FOR PREHOSPITAL
PAIN MANAGEMENT
Arthur Kanowitz, MD, Thomas M. Dunn, PhD, NREMT-B, Elyse M. Kanowitz,
5 BA, WilliamW. Dunn, BA, NREMT-P, Kayleen VanBuskirk, BA
ABSTRACT
Objective. To determine the safety and effectiveness of fentanyl administration for prehospital pain management.
Methods. This was a retrospective chart review of patients transported by ambulance during 2002–2003 who were administered
fentanyl citrate in an out-of-hospital setting. Pre and post-pain-management data were abstracted, including
vital signs, verbal numeric pain scale scores, medications administered, and recovery interventions.
In addition, the emergency department (ED) charts of a subgroup of these patients
were reviewed for similar data elements.
Results. Of 2,129 patients who received fentanyl for prehospital analgesia, only
12 (0.6%) had a vital sign abnormality that could have been caused by the administration of fentanyl. Only one (0.2%) of
the 611 patients who had both field and ED charts reviewed had a vital sign abnormality that necessitated a recovery intervention.
There were no admissions to the hospital, or patient deaths, attributed to fentanyl use. There was a statistically
significant improvement in subjective pain scale scores (8.4 to 3.7). Clinically, this correlates with improvement from
severe to mild pain.
Conclusion. This study showed that fentanyl was effective in decreasing pain scores without causing
significant hypotension, respiratory depression, hypoxemia, or sedation. Thus, fentanyl citrate can be used safely and
effectively for pain management in the out-of-hospital arena.
Michel Galinski
Centre National de Ressources de lutte
contre la Douleur - CNRD.
Hôpital 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...@googlegroups.com [mailto:naemsp...@googlegroups.com]De la part de Wegandy
Envoyé : dim. 19 septembre 2010 05:03
À : naemsp...@googlegroups.com
Objet : Re: [NAEMSP Dialog] Prehospital Pain Management
Michel Galinski
Centre National de Ressources de lutte
contre la Douleur - CNRD.
Hôpital 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...@googlegroups.com [mailto:naemsp...@googlegroups.com]De la part de Arthur Kanowitz MD FACEP
Envoyé : lun. 20 septembre 2010 05:40
À : naemsp...@googlegroups.com
Objet : RE: [NAEMSP Dialog] Prehospital Pain Management
Keith Wesley, MD
Medical Director
HealthEast Medical Transportation
St. Paul, MN
Keith Wesley, MD
drwe...@charter.net
You’re right, but it’s also about changing the thinking ABOUT BLS and ALS providers.
For example, it’s hard to insist on all-volunteer EMT services [to cut costs], and at the same time add responsibilities and training requirements associated with medication administration. In addition, the CQI process for all those calls needs to be in place. If the person accomplishing the CQI process is donating his/her time, and the EMTs are volunteer, what kind of service do you expect?
Don’t get me wrong, I have the utmost respect for those volunteering their time to train and practice out-of-hospital medicine. We have momentum now, increasing the professionalism and standardization of training for EMS providers. We need to advocate for their remuneration.
Carin M. Van
Gelder, MD FACEP FAAEM
EMS Medical Director, NHSHP
Assistant Professor, Dept of Emergency Medicine
Yale University School of Medicine
ph (203) 785-6159
Bryan
--
Bryan E. Bledsoe, DO, FACEP, FAAEM
Clinical Professor of Emergency Medicine
University of Nevada School of Medicine
Attending Emergency Physician
University Medical Center of Southern Nevada
Medical Director, MedicWest Ambulance
Las Vegas, Nevada
Interestingly, the current edition of the Carolyn AAOS Paramedic text devoted 2 pages to identifying drug seekers. This is not appropriate. No more than blowing someone off with a complaint of chest pain because you just don't believe them.
Keith Wesley,MD
Keith Wesley, MD
drwe...@charter.net
I would never advocate for a single BLS service to institute an ALS intercept simply to treat pain. Dispatch is the best time to determine whether or not the condition is one that merits pain control and then send ALS.
In the absence of ALS, or more specifically, in combination with ALS the basic skills of rest, ice, compression, and elevation work wonders. Not to mention providing a calming assurance that their pain will be addressed and get better.
As for nitrous? I'm all for it. The UK and Australia have shown that this is a valuable tool for the BLS provider. We just have to get the damn FDA to understand this and to approve the agents they are using for use here in the States.
Keith Wesley, MD
Medical Director
HealthEast Transportation
St. Paul, MN
Dear Dialog readers,
The beauty of this dialog is to inform each other of situations and
current practices which others may not be aware of. A previous
contributor suggested drug seekers do NOT dial 9-1-1. I wish that was
true for my EMS providers.
In Alaska there are vast areas where no pharmacies exist and our
volunteer EMS providers are quite fatigued and demoralized from drug
abusers calling 9-1-1. Many drug seekers have been cut off from the few
existing clinics with dispensaries and ER's, leaving 9-1-1 the only
access to a quick fix when other avenues dry up. There are various
manipulations and scenarios which these patients devise and I cannot
expect a volunteer EMS person to judge whether or not to give Morphine
and then transport to the nearest hospital which can be 100 miles away.
When a citizen takes a day off from paid employment to respond to one of
these calls, it sucks a their will to provide community service.
TWO articles are worth review:
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.
My next email will separately discuss the use of multiple controlled
substances in volunteer or rural EMS agencies.
Danita Koehler, MD
Chief, EMS
US Army- Alaska
-----Original Message-----
From: naemsp...@googlegroups.com
[mailto:naemsp...@googlegroups.com] On Behalf Of Keith Wesley
Sent: Monday, September 20, 2010 1:06 PM
To: naemsp...@googlegroups.com
Subject: Re: [NAEMSP Dialog] Re: Prehospital Pain Management
Keith Wesley,MD
Keith Wesley, MD
drwe...@charter.net
Classification: UNCLASSIFIED
Caveats: NONE
Bryan
--
Bryan E. Bledsoe, DO, FACEP, FAAEM
Clinical Professor of Emergency Medicine
University of Nevada School of Medicine
Attending Emergency Physician
Medical Director, MedicWest Ambulance
University Medical Center of Southern Nevada
Las Vegas, Nevada
(fax) -- You received this message because you are subscribed to the Google Groups "NAEMSP Dialog" group. To post to this group, send email to naemsp...@googlegroups.com
Derek
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)
My view: If they need analgesia, then they should not be triaged to a BLS unit. Period.
BTW, the dirty lawyers are beginning to wake up to the lack of pain management in prehospital care. Beware.
Gene Gandy, JD, LP, NREMT-P
-----Original Message-----
From: Derek Isenberg <derek.i...@gmail.com>
To: naemsp...@googlegroups.com
Sent: Sun, Sep 19, 2010 6:55 pm
Subject: Re: [NAEMSP Dialog] Prehospital Pain Management
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
> Sent: Fri, Sep 17, 2010 5:29 pm > Subject: [NAEMSP Dialog] Prehospital Pain Management > > > 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 here was not improvement > of pain relief neither reduction of morphine side effects (galinski Am j Emerg > Med 2007). > ketamine is not exactly an antalgic drug,; it is an antihyperalgesic drug and > sedative drug. > Ketamine can be use doses of 0.5 to 1 mg/kg IV, but it is more a sedative > action. > 2 to 3mg/kg IV are anesthesiologic doses. > > > 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 +33 144735426 > Secrétariat: +33 144735421 +33 144735421 > > -- > You received this message because you are subscribed to the Google > Groups "NAEMSP Dialog" group. > To post to this group, send email to naemsp...@googlegroups.com<mailto:naemsp...@googlegroups.com> > To unsubscribe from this group, send email to > naemsp-dialo...@googlegroups.com<mailto:naemsp-dialo...@googlegroups.com> > For more options, visit this group at > http://groups.google.com/group/naemsp-dialog?hl=en
Am J Emerg Med. 2007 Oct;25(8):977-80.
Section of Emergency Medicine, University of Wisconsin, Madison, WI 53792, USA. j...@medicine.wisc.edu
INTRODUCTION: Ketamine has been used extensively for analgesia and anesthesia in many situations, including disaster surgery where extra personnel and advanced monitoring are not available. There are many features of ketamine that seem to make it an ideal drug for prehospital use. The reported use of ketamine in the prehospital environment is limited, however. The purpose of this study is to review the experience in the use of ketamine in a regional air ambulance service and suggest indications for its use in the prehospital setting.
METHODS: This was a retrospective study of all patients transported by a regional aeromedical program. Patients were included in this study if the crew had used ketamine at any time during the flight. Data regarding the transport collected included patient age, type of transport, indications for ketamine use, and adverse reactions.
RESULTS: During the period studied, ketamine was used in 40 patients. The age range was 2 months to 75 years. The indications and situations requiring use were varied and included both trauma and medical patients. Hypotension with need for analgesia, agitation or combativeness and intact airway, or pain unresponsive to narcotic medications were the most common indications for use. Ketamine was used both intravenous and intramuscular, even without intravenous access. There were no adverse reactions.
CONCLUSIONS: Ketamine is an ideal drug for use in many prehospital situations. Our experience suggests that it is safe, effective, and may be more appropriate than drugs currently used by prehospital providers.
From:
naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of David Kim
Sent: Tuesday, September 21, 2010
7:31 AM
To: naemsp...@googlegroups.com
Subject: RE: [NAEMSP Dialog]
How much ketamine are they using? My only experience
with ketamine is with ED procedural sedation (4m/kg IM or 1m/kg IV). At
these procedural sedation doses, your ability to examine the patient and obtain
a history is nil and it may take over an hour for the effects of ketamine to
wane. I don't see how ketamine will fit into the
prehospital arena, at least at procedural sedation doses.
DTK
David T. Kim, M.D., FACEP
Idaho
Emergency Physicians, P.A.
Life Flight Network
Boise, ID
The first paper used an analgesic dose of 0.1 mg/kg IV and 1 mg/kg IM.
The second paper used an analgesic dose of 1 mg/kg IV and 5 mg/kg IM.
Quite the difference between the 2 dosages.
Fred Wu
Kaweah Delta Medical Center
From:
naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of Bryan Bledsoe, DO
Sent: Tuesday, September 21, 2010
8:06 AM
To: naemsp...@googlegroups.com
Subject: Re: [NAEMSP Dialog]
I’m on the road do not have access
to the medical school library to download the papers with the dosage
specifications. Below are two of the abstracts.
Bryan
Prehosp Emerg Care. 1998 Oct-Dec;2(4):304-7.
Emergency medical services transport of patients with headache: mode of arrival may indicate serious etiology.
Nemer JA, Tallick SA, O'Connor RE, Reese CL.
Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA.
Abstract
OBJECTIVE: To determine whether mode of arrival is associated with seriousness of etiology and use of diagnostic testing in patients treated in the emergency department for headache.
METHODS: This observational, retrospective study was conducted by consecutive review of the records of patients presenting to the emergency department with a chief complaint of headache from December 1994 through May 1995. Patients with altered mental status or seizures were excluded. Mode of arrival was classified as either by EMS or other (e.g., private vehicle). Patients with a final diagnosis of meningitis, intracranial hemorrhage, or central nervous system tumor were classified as having serious causes, whereas those with headache due to migraine, tension headache, or headache that was otherwise unspecified were classified as nonserious. The use of diagnostic studies, such as lumbar puncture or CT scan, and their results, was recorded. Patients were included in the category of patients having serious intracranial pathology even if the diagnosis was delayed. Statistical analysis was performed using the Yates-corrected chi-square test, and by determining odds ratios (ORs) with 95% confidence intervals.
RESULTS: For 967 patients presenting with a chief complaint of headache, 837 charts were included in the analysis. A total of 102 patients arrived by EMS, and 735 arrived by other means. Patients arriving by EMS had a higher rate of serious cause of headache than did those arriving by other means (OR = 18.5, p < 0.0001). EMS patients tended to undergo additional diagnostic testing (OR = 4.4, p < 0.0001), and those tests were more likely to be abnormal than for those arriving by other means (OR = 9.4, p < 0.0001). Males had a somewhat higher rate of serious diagnosis (OR = 2.6, p < 0.05).
CONCLUSIONS: In this EMS system, patients with headache who arrive by EMS are more likely to have serious causes. Mode of arrival may be of use to the clinician in assessing risk of serious illness among patients with headache. Whether this observation represents an element of self-triage or a combination of other factors remains to be determined.
With that said. I'd like to see the numbers from our colleague in Alaska. If there are that many "frequent flyers" causing problems then perhaps something needs to be addressed locally as Tarrant County did.
Keith Wesley, MD
Thank you, Dr. Wu for providing a copy of the article by Svensen & Abernathy (American Journal of Emergency Medicine (2007) 25, 977–980). I believe Mic Gunderson will be posting a copy for download on the dialog resource page.
As noted in the previous email below, procedural sedation doses were used in this study and were administered by an air medical program with a physician-nurse crew configuration. Although the use of ketamine was considered safe and effective, there was no data provided on the impact of ketamine on the patient's course at the receiving facility. The discussion section (see excerpt immediately below) discusses duration of action and attempts to minimize the potential impact on the ED evaluation but I'm extremely skeptical based on my personal experience with ketamine in the ED. Although ketamine was given by a physician in this study, the authors assert that ketamine can be safely given by non-physicians and back this statement up by providing a single reference that I have not read: Porter K. Ketamine in prehospital care. Emerg Med J 2004;21:351 - 4.
I've not seen the other paper either but the abstract below makes one wonder about the meaning of "relatively safe"!
DTK
"Ketamine induces the analgesic and dissociative state
within 60 seconds after a single IV dose and within 3 to
5 minutes for an IM dose. This sedation lasts approximately
10 to 15 minutes for IV doses and 20 to 30 minutes for IM
doses [15]. These kinetics have both advantages and
disadvantages for prehospital care. First, the duration of
analgesia and anesthesia are long enough for many transports,
and so, the patient is not overly sedated or dissociated
on arrival in the emergency department and can beduration is short enough that repeated doses may be
necessary."- For a trauma patient for example, we begin with titrated morphine:0,1mg/kg IV then 3 mg every each 5 minute; Goal: VAS or NRS = or< 3/10; no maximum dose. Limitation are side effects (nausea, vomiting, apnea). for the mobilisation we add nitrous oxide. The onset of action is 5 minutes so we have to wait 5 minutes before the patient mobilisation. The advantage with morphine is that there is an antidote (naloxone).
If we can not move the patient without pain after this stratégy , we add ketamine, moderate dose : 0,5 to 1 mg/kg iv.
We never use etomidate in this situation because there is a risk of apnea. Etomidate is for anesthesia.
The advantage of this system is the diagnosis and the efficient treatment can be done by emergency physician in setting. And after that the patient could be lead to the appropriate place.
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: DW...@schertz.com
Date: Mardi, Septembre 21, 2010 6:50 pm
Objet: RE: [NAEMSP Dialog] Prehospital Pain Management
À: naemsp...@googlegroups.com
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Michel Galinski
CNRD
Centre National de Ressources de lutte contre la Douleur
Hôpital Armand Trousseau
26, av Arnold Netter
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----- Message d'origine -----
De: David Kim <bois...@hotmail.com>
Date: Mardi, Septembre 21, 2010 4:51 pm
Objet: RE: [NAEMSP Dialog]
À: naemsp...@googlegroups.com
If it is a patient meeting your Major Trauma criteria (see CDC new guideline) then it is not appropriate to delay transfer for the reasons you stated
Keith Wesley, MD
On Sep 21, 2010, at 9:18 AM, David Kim wrote:
> I'm wondering what members of this list think about this scenario: Trauma patient who has significant pain and requires cspine precautions/packaging on a long board. The BLS non-transport unit does not immobilize due to the degree of pain and waits for ALS to arrive to administer pain meds prior to immobilization and transfer to the transport vehicle. Alternatively, ALS is on-scene first and opts to treat pain prior to immobilization & transfer to their transport vehicle. This typically involves initiation of an IV and titration of pain meds (narcotics) and potentially delays transports/prolongs scene time by 10-20 minutes. In my experience, ALS scene times are greatly reduced when the trauma patient is packeged prior to their arrival. Presumably, EMS opts to do this selectively on patients who do not appear to have immediatly life-threatening injuries.
>
> 1. Is this reasonable patient care?
> 2. Can BLS personnel reliably identify trauma patients who are unstable or potentially unstable?
> 3. Can ALS personnel reliably identify trauma patients who are unstable or potentially unstable?
> 4. What objective data or outcome measure could be used to help identify patients where this practice is undesirable?
>
> DTK
>
>
> David T. Kim, M.D., FACEP
> Idaho Emergency Physicians, P.A.
> Life Flight Network
> Boise, ID
>
>
>
>
Keith Wesley, MD
drwe...@charter.net
Laurie
Laurie A. Romig, MD, FACEP
Medical Director
Pinellas County EMS
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-----Original Message-----
From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com]
On Behalf Of Keith Wesley
Sent: Monday, September 20, 2010 2:05 PM
To: naemsp...@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
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Keith Wesley, MD
drwe...@charter.net
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The Ambulance Service of New South Wales has enabled e-mail filtering and monitoring.
Well said. I completely agree. Pain is the most common complaint in EMS and
in my experience most patients satisfaction is based more on whether or not
their pain was treated then whether or not the field "diagnosis" was
correct, what was the paramedics interpretation of the EKG, or how thorough
an exam was completed by the paramedic.
I am considering doing a statewide CQI study using pain management data
points (Initial and Final Pain Scores and treatment with opioids or other
treatment modalities) as key performance indicators, to look at how well we
treat pain statewide. It would be interesting to compare those regions of
the state without ALS to those with ALS. I certainly believe that every EMS
patient deserves pain management as early as possible. The question will be
how to facilitate pain management in those rural areas that just DO NOT have
ALS.
This is such an important topic and I thank all of you who are involved in
this discussion. Hopefully, by sharing these discussions we can dispel many
of the myths and help improve pain management in EMS worldwide.
Arthur Kanowitz MD FACEP
State Medical Director
Emergency Medical and Trauma Services Section
Health Facilities and Emergency Medical Services Division
Colorado Department of Public Health and Environment
4300 Cherry Creek Drive South
Denver. Colorado 80246-1530
office 303 692-2984
mobile 720 641-3540
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.gu...@gmail.com>
Date: Mercredi, Septembre 22, 2010 7:57 pm
Objet: [NAEMSP Dialog] Re: Prehospital Pain Management
À: NAEMSP Dialog <naemsp...@googlegroups.com>
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.
Regards
Dr Jason Bendall
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> 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...@googlegroups.com
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...@googlegroups.com
[mailto:naemsp...@googlegroups.com]De la part de Mic Gunderson
Envoy� : mar. 28 septembre 2010 03:46
� : NAEMSP Dialog
Objet : [NAEMSP Dialog] Re: Prehospital Pain Management
--