The Importance of Prehospital Pain Management
Pain is the most common reason patients call 911. Despite this, prehospital pain management has historically been inadequate, a problem known as "oligoanalgesia." Studies have shown that many trauma and medical patients arrive at the emergency department with untreated or undertreated pain. Effective pain management is not just compassionate care; it reduces anxiety, improves hemodynamic stability, decreases oxygen consumption, and improves overall patient outcomes.
Pain is subjective and personal. The same injury may cause vastly different pain experiences in different patients. As a provider, never dismiss or minimize a patient's pain report. Use standardized pain assessment tools, document pain scores before and after intervention, and treat pain within your scope of practice and protocols.
Pain Assessment
Several tools exist for assessing pain severity:
- Numeric Rating Scale (NRS): Ask the patient to rate their pain from 0 (no pain) to 10 (worst pain imaginable). This is the most common tool used in EMS.
- Wong-Baker FACES Scale: Uses facial expressions to represent pain levels. Useful for pediatric patients and those with communication barriers.
- FLACC Scale: Behavioral observation scale (Face, Legs, Activity, Cry, Consolability) for infants and nonverbal patients.
In addition to severity, assess pain characteristics using OPQRST. The quality and location of pain provide diagnostic clues (burning chest pain suggests cardiac origin, sharp pleuritic pain suggests pulmonary cause), and changes in pain after treatment help evaluate intervention effectiveness.
Pharmacological Pain Management
Available medications vary by scope of practice and local protocol. Common prehospital analgesics include fentanyl (fast-acting opioid, 1 to 2 mcg/kg IV or intranasal, short duration), morphine (classic opioid analgesic, 0.1 mg/kg IV, longer duration, causes more histamine release), and ketamine (dissociative agent with analgesic properties at sub-dissociative doses of 0.1 to 0.3 mg/kg IV, useful when opioids are contraindicated). Non-opioid options include ketorolac (an NSAID useful for renal colic and musculoskeletal pain) and acetaminophen IV where available.
Non-Pharmacological Techniques
Non-pharmacological pain management should complement, not replace, appropriate medications. Effective techniques include proper splinting and immobilization (reducing movement of injured extremities dramatically decreases pain), positioning for comfort, ice application for acute injuries, verbal reassurance and distraction, and controlled breathing exercises. For pediatric patients, distraction techniques such as conversation, counting, or having the child blow bubbles are particularly effective and should be used alongside pharmacological treatment when indicated.