Pain management is a crucial paramedic and EMR function in pre-hospital care. It aims to improve outcomes and patient experience, targeting an acceptable pain level rather than complete elimination. Effective pain control can facilitate assessment and treatment of other issues. The paramedic's approach and communication significantly impact analgesic effectiveness.

• Use a multimodal approach to control pain.  Combining diverse analgesics reduces overall opioid use and provides a more comprehensive approach to pain.  Opiates should be reserved for cases where non-opiate analgesics have been ineffective and other rapid analgesics such as nitrous oxide are unavailable.  Even when it’s necessary to utilize opiates for pain, non-opiate agents may reduce the volume of opiates a patient will require over the course of their care.  
• Non-pharmacological and basic pharmacological treatments are foundational. Include non-pharmacological approaches such as reassurance, gentle handling, local cooling, limb/body positioning, and injury splinting where appropriate. 
• Pain scales should be frequently reassessed and documented.  Both numerical and visual pain scales are valid, including the Faces/Legs/Activity/Cry/Consolability (FLACC) scale for pediatrics.
• Pain management should be goal oriented.  Goals include reduction in reported pain, minimizing medication-related side effects, and improving patient experience.  BCEHS has adopted the pain triangle to inform goal-oriented analgesia.  Invasiveness of analgesia delivery (PO/IN/IM/IV) and risks associated with each agent should be considered, especially in pediatrics where procedural pain may be a greater concern to the patient.

• Continual reassessment and documentation of effects of the interventions are important to inform trajectory of pain analgesia planning. Where patients are unable to describe their pain effectively because of language barriers, altered levels of consciousness, age, or dementia, other signs of pain can be monitored.  Consider facial expressions, guarding of limbs, tears, crying, moaning, restlessness, heart rate, and blood pressure – all may provide clues to pain experienced.
• Acetaminophen, ibuprofen, ketorolac, and nitrous oxide are effective, low-risk, and non-invasive forms of potent analgesia that may address pain completely or may limit the volume of opiate analgesics required to successfully manage pain.
• Fentanyl and morphine are equally effective opioid analgesics. The decision to treat with fentanyl vs morphine should be weighed against the timeliness required for analgesia and duration of analgesic effect. Morphine has a slower onset than fentanyl but a longer duration. Combining opioids should generally be avoided.
• Fentanyl is less likely to cause side effects as it has more affinity for the opioid receptor. Morphine has more associated side effects (nausea, vomiting, constipation). Hypotension is a consideration of all narcotic analgesics and the risk versus benefit must be weighed when treating hypotensive patients.
• Ketamine provides excellent analgesia, sedation, and dissociation dependent on dosing. Ketamine may be considered as an alternative or to be used in conjunction with opiate analgesics for severe pain.  Advantages of ketamine include opiate sparing, maintenance of airway reflexes, less nausea, and lesser hemodynamic compromise in comparison to opiates.  Ketamine has a higher frequency of minor adverse effects such as emergence, and dissociation which may be a positive or negative impact dependent on intended effect. 

Analgesia

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