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with a précis of my thoughts on pre-hospital analgesia for the @RoySocMed Pain Section and @AnaesthesiaRsm . Thanks for having me along to your meeting.
with a précis of my thoughts on pre-hospital analgesia for the @RoySocMed Pain Section and @AnaesthesiaRsm . Thanks for having me along to your meeting.
Probably the first analgesic agent used was alcohol. Injured soldiers and sailors would be offered a tot to ease the pain.
Probably not great practice, hypotension, aspiration and hypothermia all increased. I'd suggest we can do better
Probably not great practice, hypotension, aspiration and hypothermia all increased. I'd suggest we can do better
Field medics used morphine tablets during the First World War. Problems with gastroparesis induced by pain and shock probably limited it's effect.
Back then, you could buy the stuff over the counter!
Back then, you could buy the stuff over the counter!
More recently, we moved to IM morphine. More effective, but still not well absorbed.
Autoinjectors widely issued during the Cold War. Risk of incorrect use is a patient in pain, and a friend with a thumb full of morphine.
Autoinjectors widely issued during the Cold War. Risk of incorrect use is a patient in pain, and a friend with a thumb full of morphine.
There are significant obstacles to good analgesia in pre-hospital care. That said, it's an essential part of what we do, and it's often the thing patients remember for many years.
Time is not on our side, and we share it with the patient. There's a tension between taking time to titrate analgesia, versus delaying movement to definitive care.
It's hard to assess injuries with no imaging.
I recall being taught no analgesia before full diagnosis. I think that's wrong, and inhumane.
A calm patient is easier to examine, and removing pain takes away one potential cause for their tachycardia.
I recall being taught no analgesia before full diagnosis. I think that's wrong, and inhumane.
A calm patient is easier to examine, and removing pain takes away one potential cause for their tachycardia.
Access to the patient can be tricky, and this may list our options. Inhaled or intranasal techniques can be used in entrapped patients.
IV access is taken for granted in hospital.
Cold, pain and fear, as well as access to the patient all make it more difficult.
Cold, pain and fear, as well as access to the patient all make it more difficult.
Analgesic options open to paramedics have increased greatly in the past few years. IV morphine is well established, along with IV paracetamol.
Specifically trained Critical Care paramedics administer ketamine for analgesia and procedural sedation.
Even in small doses, it can make a huge difference where morphine isn't enough. Also less risk of hypotension in the hypovolaemic patient.
Even in small doses, it can make a huge difference where morphine isn't enough. Also less risk of hypotension in the hypovolaemic patient.
General anaesthesia is an option for Critical Care teams. Analgesia alone is rarely a sufficient indication, unless there are massive, mutilating injuries, or high volume IO resuscitation is needed.
The drugs do work, but they are only part of the toolkit.
Splintage significantly reduces the pain from fractured limbs, and can reduce bleeding. Reduces the need for drugs, especially in transit.
Regional techniques are an area of future development. Fascia iliaca blocks are easy, effective, and may improve the experience of hip fractured patients en route to ED, as well as expediting admission to orthopaedic wards. https://bmjopen.bmj.com/content/9/12/e033398
Keeping the patient warm has positive physiological, and psychological effects. Proper packaging makes transfer easier.
Having a competent team, who can provide confident care builds trust in frightened patients. Rapid, effective pain relief helps immeasurable to aid this.
Does it work?It's difficult to say. Studies are limited, and mostly show we're bad at recording pain scores.
But lack of analgesia remains a common complaint from patients, so we evidently have a way to go to improve from here.
Our role in PHEM is rarely to save life. Our job is to be the first link in the rehabilitation chain. That's what will give them back the life they want.
Good acute pain relief reduces chronic pain, and improves rehab right from the start.
Good acute pain relief reduces chronic pain, and improves rehab right from the start.
Exits, pursued by a bear.
Never done this thread thing before. Any good?
Never done this thread thing before. Any good?
