The relief of pain is one of the most significant and meaningful interventions paramedics and EMRs perform in the out-of-hospital setting.  It is expected that paramedics and EMRs will provide timely and effective pain management to all patients in their care.  Controlling pain can calm patients and assist in the assessment and management of other clinical problems.  The demeanour and language used by paramedics and EMRs can dramatically influence the efficacy of any analgesic strategy - even opioid-based analgesia will not work if patients do not trust their providers

• Always use a progressive and multimodal approach to controlling your patient’s pain. Non-medication strategies have proven effects to decrease patient pain.  Always progress from the simplest to the more invasive or complicated medication deliveries.  Do not forgo basic strategies in favour of more complicated approaches.
• As part of a progressive and multimodal approach, consider all benefits and effects of interventions as part of your patient’s pain management. For example, with the knowledge that acetaminophen and ibuprofen have the same effects as an opioid medication but take longer for effect, administer early and bridge with another medication (eg. nitrous oxide) while awaiting the onset.
• Typical measures should always include reassurance, gentle handling, control of temperature, positioning of the patient or limbs, and splinting of injured limbs.
• As interventions are applied, continue to assess and record their effects.
• An inability to report or rate pain should not preclude analgesia.  Where discomfort is evident in the setting of potentially painful stimuli, consider options for analgesia. The pain ladder is an effective tool to assist in rating the patient’s pain and response to pain management.

• When combined with positive reinforcement, nitrous oxide (Entonox) is an effective analgesic.  It is the agent of choice in many countries for use in childbirth.  The contraindications to the use of nitrous oxide are the result of the pathophysiology of gas exchange and absorption (primarily the trapping of gas and the development of hypoxia). 
• Nitrous oxide can cause rebound hypoxemia due to the displacement of oxygen from the alveoli as it diffuses out of the bloodstream.  Supplemental oxygen following the use of nitrous oxide will prevent the development of this hypoxemia and should be provided to all patients. 
• Acetaminophen daily maximum dose is not to exceed the lesser of 75 mg/kg or 3,000 mg in a 24-hour period. This includes any medications containing acetaminophen that was consumed prior to paramedic administration.
• Methoxyflurane (Penthrox) daily maximum dose is 6 mL in a 24-hour period. This dose includes any provided by first responders e.g. ski patrol and cannot be exceeded.
• Methoxyflurane (Penthrox) is contraindicated in known or suspected pregnant patients
• Fentanyl is an opioid analgesic.  It is generally less prone to causing hypotension than morphine, though a drop in blood pressure is likely once adequate analgesia is achieved due to a reduction in overall sympathetic stimulation.  Fentanyl does not provide a greater degree of analgesia than morphine.
• Ketamine provides excellent analgesia, sedation, and dissociation dependent on dosing.  As an analgesic, ketamine has significant advantages in the out-of-hospital setting: it allows the patient to breathe spontaneously, maintain many of their own protective airway reflexes, and tends to elevate blood pressure through the release of catecholamines.

• Approach each call with a view to assessing a patient’s pain and exploring ways to help alleviate it.
• Every intervention and medication has important side effects.  Some of these may actually worsen a patient’s pain or experience.  Always use interventions most likely to provide positive assistance.
• As interventions are applied, continue to assess and document the effects of the interventions by measuring the patient’s pain.  In cases where patients are unable to describe their pain effectively (because of language barriers, altered levels of consciousness, age, or dementia), other signs of pain must be monitored.  Consider the use of facial expressions, the guarding of limbs, tears or crying, moaning, restlessness, heart rate, and blood pressure – all may provide clues and allow paramedics and EMRs to manage pain more effectively.
• In special populations, specific pain assessment tools may be useful.  Consider the FLACC scale in children or the Abbey scale in adults with dementia.

Analgesia

1. Derry CJ et al. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. 2013. [Link]
2. Krebs EE et al.  Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain the SPACE randomized clinical trial.  2018.  [Link]
3. Lindbeck G et al. Evidence-based guidelines for prehospital pain management: recommendations. 2022. [Link]
4. Sobieraj DM et al. Comparative effectiveness of analgesics to reduce acute pain in the prehospital setting. 2020. [Link]
5. Teater D. Evidence for the efficacy of pain medications. n.d. [Link]

• 2023-02-06: updated guideline to reflect changes to scope of practice for EMRs and introduction of methoxyflurane into practice. 
• 2023-02-13: fixed spelling error