Pain priorities in pre-hospital care

Abstract

Pain management in the pre-hospital environment is a priority following life- and limb-saving manoeuvres. Pain should be assessed, documented and managed according to a multimodal model. Even in the context of environmental challenges and limited resources, pharmacological, physical and psychological interventions can be used to provide effective analgesia and relieve suffering prior to and during transfer to hospital.

Learning objectives

After reading this article, you should be able to:

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outline the challenges to pain management in the pre-hospital environment
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discuss a method of pain assessment in the pre-hospital environment
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list the pain management strategies in the pre-hospital environment

General principles

The management of pain in the pre-hospital environment provides several challenges to the pre-hospital clinician. These include:

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variety of injuries
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patient comorbidities
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patient anxiety
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exposure to environmental extremes leading to hypothermia or hyperthermia
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significant physiological changes rendering some routes of administration unreliable
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isolation from specialist advice
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limitations of pre-hospital practitioners’ knowledge, expertise and equipment
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exacerbation of pain by patient movement, vehicle vibration, motion sickness
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danger to patient and physician.

Being injured hurts; more than two-thirds of military casualties describe their pain as moderate or severe at the point of injury. After treatment of life- or limb-threatening injuries, and assessment and management of respiratory, haemodynamic and neurological systems, pain management should be addressed.

The ideal pre-hospital analgesic agent would be available to all pre-hospital practitioners, have a rapid onset, be easy to titrate, relieve moderate and severe pain and be free of side effects such as nausea and vomiting, respiratory and haemodynamic depression. Unfortunately, none of the currently available analgesics matches these requirements so pain relief should be provided following risk-benefit analysis.

Assessment

Timely and accurate pain scoring allows assessment of analgesic requirement and appraisal of analgesic efficacy. There are a number of scales that can be used to assess pain and, ideally, the scale used should be the same as that used in the receiving unit allowing an integrated approach to pain management. The chosen scale should be easy to use and reproducible (for an example see Table 1 ). Scores should be documented both prior to, and following, analgesic administration and handed over to the receiving team, ideally on a standardized document. Whichever scale is used, a pain score more than one-third of the maximum is a ‘failure’ of analgesia.

Table 1

Pain assessment scale