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 assessment and management of other clinical problems. The demeanor and language used by paramedics and EMRs can dramatically influence the efficacy of any analgesic strategy: even narcotic analgesia will not work if patients do not trust their providers.
Use a step-wise approach to controlling pain, moving from the simplest to more invasive. Never neglect the basics in favour of more complicated approaches.
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 possible painful stimuli, consider options for analgesia.
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. Use those predicted to help.
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.
First Responder (FR) Interventions
Keep the patient at rest and in a position of comfort
Splint/support any injured extremity
For injuries, consider ice packs or heat packs applied to injury site in conjunction with elevation where clinically appropriate
Emergency Medical Responder (EMR) & All License Levels Interventions
MORPHine is reserved for the management of pain in patients receiving palliative care
Nausea associated with the administration of fentaNYL and ketAMINE is rare and there is no need to administer anti-emetics prior to analgesia; they may be considered if nausea develops after administration:
The clinician must discuss risks, benefits, and alternatives of the procedure and planned analgesia with the patient.
Identify your goal of care.
Select the right medication at the right time for the right patient. While utilizing the right route at the right dose for the presenting disease or injury.
Safest dosing is the lowest dose to accomplish your goal of patient compliance. Ideal body weight or lean body weight is best used for most medications.
Give the medication time to work as to not overshoot your goal of care. Understand each medication for onset, peak effect, and half-life as to aid in decision making.
Repeat as necessary only after a subsequent risk assessment.
Stop and intervene if any untoward effects are found.
Dosing ranges are dependent on individual needs and comorbidities. Titrate appropriately for the individual and goal of care. Ideal or lean body weight should be used for all the medications below. The dosing is based on single agent use and not multiple agents. The use of multiple agents increases the risks associated and should be avoided when possible. For those instances where multiple agents are needed a dose reduction is advised.
Weight ≥ 50 kg < 65 years of age (15 - 30mg IV max 120 mg daily) Adult
Weight < 50 kg or ≥ 65 years of age (15mg IV max 60 mg daily) Adult
(0.5 mg/kg to a max of 30 mg daily) Pediatric
(500mg- 1g q6hrs to a max 75 mg/kg or 4 grams in 24 hours PO) Adult
(10-15 mg/kg q6hrs to a max of 75 mg/kg or 4 grams in 24 hours PO) Pediatric
(1-2 mcg/kg to a max of 200 mcg IV) Adult
(1-2 mcg/kg to a max of 50 mcg IV) Pediatric
(2-4 mg to a max of 10 mg) Adult
(0.025- 0.05 mg/kg to a max of 5 mg IV/IO) Pediatric
(0.2 – 0.5 mg/kg to a max of 50 mg IV) Adult
(0.2 – 0.5 mg/kg to a max of 50 mg IV) Pediatric
(0.2-1 mg to a max of 1.5 mg IV) Adult
(0.01- 0.015 mg/kg to a max of 0.5 mg IV) Pediatric
Other Notes or Resources:
Total acetaminophen dose is not to exceed the lesser of 75 mg/kg or 4 grams in 24 hours.