Non-Traumatic PainAdvanced EMT Class

What is pain?

• "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"

• - 1975 , International Association for the Study of Pain

“There is a common belief that wounds are inevitably associated with pain, and, further, that the more extensive the wound the worse the pain. Observation of freshly wounded men in the combat zone showed this generalization to be misleading…..”

LTC Henry K Beecher, Medical Corps, Army of the United States

Objectives

• Review types of Pain• Discuss assessment of Pain• Review and Discuss common non-traumatic (and non-cardiac) causes

of pain• Review common treatment modalities

Pain and EMS

• Approximately 15% of EMS calls are for a primary complaint of pain…• Many more have it as a secondary complaint

• Whether our patients are suffering from a traumatic, medical or psychological condition, a common thread throughout many of our calls is pain.

• Definition from the International Association for the Study of Pain: “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage…”

Pain Serves a Purpose

• It tells us something is wrong with our body that we can’t see otherwise• Appendicitis• Internal bleeding

• It helps us avoid dangerous things• We touch a hot stove, we feel pain, we pull away

• It helps us protect damaged body parts• We shield injuries from accidental contact with other people or things

The Bad Side of Pain• While pain serves an important purpose, it also

presents a barrier to normal functioning• Pain negatively affects:• Attention• Memory• Mental flexibility • Problem solving • Information processing speed• Stress levels

Pathophysiology…and psychology …of pain

Pain…..

• Rene’ Descartes• Cartesian Theory of pain• French Philosopher that first

proposed that pain was a disturbance that passed down along nerve fibers until the disturbance reached the brain.

What Causes Pain?

• Pain signals are sent to our brain by nociceptors (no-si-sep-tors)• A nociceptor responds to damaging stimuli (heat, pressure, etc.) by

sending nerve signals to the spinal cord and brain.• This process, called nociception (no-si-sep-shun), is what causes the

feeling of pain.

The Pain Pathway (tutorvista.com)

Is it this simple?

• In everyday medicine, doctors see pain in Cartesian terms—as a physical process, a sign of tissue injury. • We have known that this is not the “full picture” since the early

1900’s.

Pain has a psychological and a social-situational aspect• Lt. Col. Henry K. Beecher (WWII) wrote: “ Pain in wounded men in battle”.

Studied 225 soldiers at a various forward aid stations at multiple major engagements. • 58 % with severe injuries reported only slight or no pain • On 27 % felt enough pain to request pain medication• This flys in the face of traditional Cartesian understanding of pain.

• Proposed that there were THREE main components of pain…• Mental Distress• Thirst, dehydration, and discomfort• Pain from injuries

• Goes on to write that medical treatment has been mainly focused on the painful injury, and ignoring the psychological and social aspects.

Gate- Control Theory

• Builds on the Cartesian theory of pain, but states that the pain impulses go through “gates” in the spinal chord. These gates have the ability to mute, eliminate, or amplify pain.• They also state that there are physiological and psychological factors

that influence these “gates”.

Melzack R. The puzzle of pain. New York: Basic Books; 1973. ISBN 465067794.

Visual cues affect pain perception

• Additional research has shown that the experience of pain is shaped by a plethora of contextual factors, including vision. • Researchers have found that when a subject views the area of their body that is

being stimulated, the subject will report a lowered amount of perceived pain.• For example, one research study used a heat stimulation on their subjects' hands. When the

subject was directed to look at their hand when the painful heat stimulus was applied, the subject experienced an analgesic effect and reported a higher temperature pain threshold.

• Additionally, when the view of their hand was increased, the analgesic effect also increased and vice versa. This research demonstrated how the perception of pain relies on visual input.

Mancini, Flavia. "Visual Distortion of Body Size Modulates Pain Perception." Psychological Science. (2010): n. page. Web. 9 Dec. 2011.

Sometimes we don’t even need an injury to make pain occur. • If I say “Pain is all in the head” what do you think that means?

Neuro-Programs?

• If Y = Pain response…

• What if?• If X then Y • What if Z then Y? • What if (ABC), but not (CBA), then Y?• What if (null) then Y?

• Melzack , et al, proposes that acute pain is “Lateral Pain” wich skips along the outside of the brain stem, and chronic pain is “Medial Pain” which passes directly through the brain stem. • The fore he proposes that each type of pain is actually different disease processes

with different approaches.

Classifications of Pain (from Mosby’s Paramedic textbook)

• Acute – sudden in onset, subsides with treatment• Chronic – persistent or recurrent, hard to treat• Referred – pain felt somewhere other than its origin• Heart attack felt in arm• Spleen rupture felt in shoulder• Gall bladder felt in shoulder blade

Classifications of Pain (from Mosby’s Paramedic textbook)

• Somatic – pain in muscles, ligaments, vessels, joints• Superficial – pain in skin, mucous membranes• Visceral – “deep” pain, hard to localize, arises from smooth muscles

or organ systems

Referred Pain• Pain that originates in a region other than where it is

felt• Arm/Jaw Pain Acute Coronary

Syndrome

• Pain between Dissectingshoulder blades Thoracic Aortic

Aneurysm

- Shoulder Pain Liver Injury

(Paramedic Care: Principles and Practice)

Some other kinds of pain

• Neuropathic – caused by damage or disease to the nervous system• Tingling, burning, electrical “zapping” • “Pins and needles”• Bumping the “funny bone”

• Psychogenic – caused by mental, emotional, or behavioral factors• No less hurtful than pain from other sources• Not “all in their head”

Phantom Pain• Phantom – felt after limb is amputated• Nerve endings to stump become “confused”• Signal pain to the brain even though the limb

is no longer there.

Inability to Feel Pain

• Some people can’t feel pain like they should• Diabetic neuropathy• Spinal cord injury• Congenital disorders

• More prone to injury due to lack of “warning”• May be shorter life span due to increased injury risk

Pain Tolerance

• Several studies over the years have shown women typically display lower pain tolerance than men.• Unknown whether reason is hormonal, genetic or psychosocial.• Researchers suggest men more tolerant of pain because of “macho”

stereotyping, while feminine stereotyping encourages pain expression.

Pain Tolerance

• On the other hand, the show “Mythbusters” recently found women to be more tolerant of pain than men, so stereotypical responses may be changing over time.

On the other, other hand….

• Melzack and Walls Ballet Study:• 52 Dancers from British Ballet company• 53 physicaly fit university students

• “Cold Compressor” Test• Place hand in room temp water for two minutes-> immerse in ice

water-> TIME: Pain felt (Pain THRESHOLD) -> Pain is too much to keep hand in (Pain TOLORANCE)• Results: Males tended to last longer than women in both groups. BUT,

dancers tended to last 3x as long as the students. Why?

Placebo effect:

• Foolish or simply recruiting the patients mind (the psychological component )in pain management?• Should we lie to our patients?• Should we manage expectations?

Some other things to consider

• There is some thought that some panic disorders and some pain disorders (and the chest pain associated with them) originate from the same part of the brain (the Thalamus)• Social factors have been known to strongly effect pain perception and

epidemiology. • Satisfying work environment• Marriage/relationships• Stress

KEY POINT:

• Pain that arises from a psychological/social origin is no less real to the patient than one arising from a physical injury. Only the effective therapies may be different.

Assessing Pain

What is pain?

"Those who do not feel pain seldom think that it is felt." - Dr Samuel Johnson (1709-1784)

Assessing Pain

• The most basic way to characterize pain is the 1-10 scale (some use 0-10).• All reports/narratives with patients in pain should include a 1-10

rating both before, and after, treatment• 1 (or 0) = no pain• 10= worst pain ever felt

Assessing Pain

• For children and others with difficulties understanding the 1-10 scale, you can use the Wong-Baker scale• Also called the “smiley face” scale

• They point to the picture that best describes their pain.

Wong-Baker Scale

Assessing Pain - OPQRST• All narratives for pain and injury should include some form

of OPQRST• O – Onset (when did pain start)• P – Palliation/Provocation (what makes it better or worse)• Q – Quality (what does it feel like)• R – Radiation (does it move anywhere)• S – Severity (1-10 scale)• T – Time (can be combined with O, or can refer to whether it comes and

goes or is steady)

• You don’t have to specifically reference each letter in your report. • Like any mnemonic, it’s more to help you remember important

assessment questions, than to actually be used word-for-word.

• But if the information is relevant, it needs to be included somehow.

Assessing Pain

• What does patient look like?• Obvious distress?• Guarding injured limb?• Yelling?• Calm and controlled?• Tense?

• Does the patients presentation match the report of pain?

Assessing Pain

• Remember DCAP-BTLS?• All painful or injured body parts need to be exposed and examined.• And all examinations need to be documented.• Exception – obvious cardiac chest pain, but if you are putting on EKG leads,

you might as well examine and document anyway since you are there.

Assessing Pain – Head-to-Toe

• Depending on the mechanism of injury or the nature of the illness, a head-to-toe exam may be called for too.• Document all head-to-toe exams. If it’s not written down, it wasn’t

done.• Don’t let severe pain from one part of the body distract you from

injuries on other parts of the body.

Assessing Pain - Peds

• Sometime starting at the toes and working your way up to the head works better with kids.• May be less likely to freak out.

• “No Surprises” Policy – • Kids fear the unknown, and they fear being alone. • Keep it simple and in the “Now”• They fear “Forever”

• Kids are the kings and queens of distracting injuries. • They don’t understand why a bloody finger is less important than a deformed

leg.• Take extra care in examining a child in pain

Pain Management

Pain Management

• Because pain has as many bad aspects as good, our goal in EMS is to control pain whenever possible.• Joint Commission (JCAHO) says pain is 5th vital sign after BP, pulse,

respiratory, and temp.

• The goal – ZERO PAIN!

Why Zero Pain?

• Cardiac chest pain – zero pain means less stress on the patient, lowering pulse and BP, leading to less work for the heart• Musculo-skeletal pain – zero pain means your patient is more

cooperative, less disruptive and better able to follow directions

When is zero pain not the goal?

• There are a few times in EMS when we don’t want to treat pain• Headache – pain medication can mask symptoms of a more serious head

injury• Abdominal pain – pain location is often used for diagnosis of new-onset

abdominal pain• Drug-seeking patient – trust your instincts

• If you suspect patient is a drug-seeker, let medical control know your suspicions (out of earshot of patient)

When are we extra- cautious with pain control?• Patient is already self medicated• Alcohol• Head Injury/Altered LOC• Borderline Blood Pressure• Elderly

Dr. Kraners theory of pain control and blood pressure• That most opioids are not as vasoactive as previously thought• That it is the pain that is “vaso-active” in keeping blood pressure up. • If we see a severe drop after administering analgesia, perhaps somne

of that is the actual underlying blood pressure• If we are relying on the pain response (i.e. adrenalin and nor-epi) to

keep blood pressure up, we may be promoting cellular hypo-perfusion through capillary vaso –constriction• Solution- Medicate conservatively and fluid resuscitate unless

contraindicated.

EMS and Pain

• Prehospital Emergency Care, Jul-Sep 2010… pain in prehospital emergency medicine affects 42% of patients…. Pain management is inadequate, as only one in two patients experiences relief.”

• American Journal of Emergency Medicine, Oct 2007… “women are less likely than men to receive prehospital analgesia for isolated extremity injuries… Increasing levels of income were associated with increased rates of analgesia.”

Why are we not treating pain adequately?• Biases and prejudices?• Poor patients, patients we think are faking it, patients who are “whiners”

• Fear of medication administration?• Giving narcotics is a big responsibility, especially if we are not comfortable

with our skills and math ability• Administrative and logistical hurdles?• Narcotics control procedures cumbersome • Push back from chain of command for being bothered with narcotics

procedures.

Discussion Questions• Why don’t we relieve pain? • Obstacles to pain management • Options for ALS providers

Why are we not treating pain adequately?

• Our own emotional reaction to someone in pain?• Our anxiety can cloud our judgment regarding treatment• A screaming patient makes even the best medic second-guess

• Past issues with medical control regarding medication administration?• In the old days, paramedics often got hassled for attempting ALS pain

management. Sometimes, they still do.

Non Pharmacological Treatment of Pain

Pain pharmacology/treatment• Pain medications/treatments address two

components of pain:• The actual sensation of pain• The emotional response to pain

• We carry medications and treatments on the ambulance that address both components• Don’t forget BLS treatments… often just as effective as

ALS medications, and easier too.

Cold Packs

• Cold packs often a forgotten element of pain management.• Remember the “Gate Control Theory”?• In addition to reducing swelling, there is a theory that cold “Opens” the gate

for cold sensation impulses, decreasing the actual pain impulses that get through.

• Reduce swelling and pain in strains, sprains and fractures.• When possible, do not put directly on injured area.• Can cause tissue damage• Wrap in pillow case or gauze first

Splinting• Splinting used to stabilize damaged bone ends, or

injured muscles/ligaments.• But also useful in reducing pain caused by movement

of injured areas.• Whether a commercial splint, or a pillow and tape… a splint is

powerful weapon against pain.• Traction splint significantly reduces pain of femur fracture by easing

muscular contraction

• Check distal pulses, movement and feeling (“MSC”, “CMS”, “PMS”) before/after splinting.

Distraction?

• Conversation• Music• Video

Pharmacological Interventions

The Ideal Analgesic

• Safe with few side effects• Effective and rapid acting• Easy to administer, store, and carry• Of short duration and easily reversible• Not easily abused

Opioids/Opiates

• Scrolls describing its use date back almost 5000 years• Bind with opioid receptors in the brain and

elsewhere• Alters perception of pain• Alters emotional response to painful stimulus

Drugandalcoholrehab.net

Opioids

• Commonly carried by EMS• Chief alkaloid of opium• Carried by prehospital crews because• It’s cheap• It’s been around a long time• It works without too much fuss• It’s easy to treat if we give too much of it

• Ventilation and Narcan

Common Opioids

• Morphine• Fentanyl• Dilaudid• Demerol

Opioid side-effects

• Respiratory depression• Nausea/vomiting• Constipation• CNS depression• Careful administration can prevent many of these side-effects

Benzodiazepines/Sedatives• Benzo’s are used in many EMS systems for drug-

assisted intubation, seizure control and chemical restraint.• Some systems also order a benzodiazipine as muscle

relaxant in long bones fractures, back injuries, and hip fractures.• Also to reduce anxiety in patient with pain.• Versed (A type of benzo) given to reduce pain of

cardioversion and pacing, as well as to induce amnesia.

Benzodiazepines/Sedatives

• Benzo’s are sedatives, similar to opioids but working through a different mechanism.• GABA• Same mechanism that Alcohol causes its sedative effects.

Common Benzo’s

• Diazepam (Valium)• Midazolam (Versed)• Lorazepam (Ativan) Not used in EMS:• Clonazepam (Xanex)

Prince Valium, from the Princess Bride

Anesthetics• Anesthetics are CNS depressants.• Act on nervous tissue

• Two main anesthetics in EMS system• Tetracaine – local anesthetic

• 1 to 2 drops as needed for (closed) eye injury• Nitrous oxide – inhaled anesthetic

• Broken bones, non-respiratory burns, kidney stones• 50/50 concentration with oxygen• Contraindications – AMS, shock, abd trauma, facial injuries, COPD,

head injury

Nitronox-Properties

• Blended mixture of 50% nitrous oxide and 50% oxygen • Also known as “laughing gas”• Produces sedation and analgesia• Colorless, odorless, heavier than air • Nonexplosive, nonflammable• Readily diffuses through membranes (rapid onset, short duration after

inhalation is stopped)• Provides a sedative effect which decreases the patients perception of pain• May partially act on opiate receptor systems to cause mild analgesia

Nitrous Oxide

• Drug Name: Nitrous Oxide, N2O• Trade Name: Entonox, Nitronox• Class: Inhaled gas, dissociative anesthetic• Mechanism of Action:

• The pharmacological mechanism of action of N2O in medicine is not fully known. It appears to have multiple , diverse, neurochemical effects in the body, mainly in the central nervous system. It produces its analgesic, hallucinogenic, and euphoric effects through effects on dopamine, opioid, GABA and seratonin receptors.

• It is absorbed, and eliminated via the respiratory system. It does not accumulate for any significant period, but tolerance has been known to develop similar to opioids.

Nitrous Oxide

• Indications: • Painful injuries

• Contraindications:• Inability of the patient to hold mouthpiece or control their own airway. • Hypoxia• Suspected bowel obstruction• Abdominal Injury• Suspected Pneumothorax,• inner/Middle ear disorders• SCUBA diving within previous 24 hours.

Nitrous Oxide

• Precautions:• Psychiatric Emergencies• Use of opioids, alcohol, and benzodiazepines• While it has been used in pregnancy and during labor, thereis some evidence

that it may increase the incidence of spontaneous abortion. use only with medical control approval in pregnant patients.

• Dosage:• Adults: Self administered at pre-set levels. • Pediatrics: Self administered at pre-set levels. • EMS Nitronox typically comes in a 50/50 mixture

Nitrous Oxide

• PEARLS: • Nitrous Oxide typically comes pre-mixed with 50% Oxygen. It is typically

administered via a demand valve, mouth peice or a mask. • Nitrous Oxide is ineffective in up to 20% of the population. • Nitrous oxide is more soluble than oxygen and nitrogen, so will tend to diffuse

into any air spaces within the body. This makes it dangerous to use in patients with pneumothorax or who have recently been scuba diving, and there are cautions over its use with any suspected bowel injury or obstruction.

• Its analgesic effect is strong (equivalent to morphine ) and characterised by rapid onset and offset (i.e. it is very fast-acting and wears off very quickly).

• Cautious use in enclosed spaces

Nitronox Administration

• ALWAYS SELF – ADMINISTERED BY PATIENT WHO IS AWAKE, ALERT, AND COOPERATIVE!• Instruct patient to inhale deeply through the patient-held demand

valve• Patient determines number of inhalations and duration of therapy

required for adequate pain relief

Delivery Unit

• Supplied in carrying case containing 2 cylinders, 1 nitrous oxide and 1 oxygen• Mixing valve ensures premixed 50:50 delivery of gas• Demand valve prevents free flow of gas when not in use by patient• Negative pressure required to open demand valve (good seal and

patient effort)

Delivery Unit (cont.)

• If oxygen tank runs out- audible alarm and no gas delivery

• If nitrous oxide tank runs out- audible alarm with 100% oxygen delivery to patient

Take a break…

Some specific examples

Chest Pain• Initial treatment does include aspirin• But not for pain, for better cardiac outcome

• ZERO pain comes from:• Nitro – vasodilates, reduces workload of heart

• If initial nitro doesn’t reduce pain, repeat x2 in 5 minute increments if BP > 90 systolic and IV established

• Opioids – reduces muscle pain, reduces stress, reduces workload of heart (reduces preload)

Isolated Extremity Injury• First control bleeding with direct pressure and

elevation.• Splint fractures, sprains and strains• BLS – a cold pack can reduce swelling and pain• ALS – nitrous oxide can help with fractures• If patient is able to self-administer w/injuries

• ALS – Opioids• No opioids if hypotension from blood loss.

Back Pain

• Though the yearly prevalence is stable at 15% to 20%, nearly 80% of adults will experience back pain at some point during their lifetime, with 31% of patients annually requiring time off from work• Varies from acute, to chronic, and acute exacerbation of chronic pain

Back Pain

• Muscle strain and spasm• Lumbar• Diffuse right and/or left• Palpable tetany of muscles• Classic Presentation: Doesn’t

want to move…

• Sciatica• “Sciatic Pattern”• May or may not be associated

with muscle spasms

Kidney Stones

• Classic presentation: • Sudden Onset• Flank Pain• “Cant find position of comfort” – Squirmy• Severely decreased urine• Hematuria

Generic Abdominal Pain

• Regarding Abdominal Pain: Narcotic analgesia was historically considered contraindicated in the pre-hospital setting for abdominal pain of unknown etiology. It was thought that analgesia would hinder the ER physician or surgeon's evaluation of abdominal pain. It is now becoming widely recognized that severe pain actually confounds physical assessment of the abdomen and that narcotic analgesia rarely diminishes all of the pain related to the abdominal pathology.

• It would seem to be both prudent and humane to "take the edge off of the pain" in this situation with the goal of reducing, not necessarily eliminating the discomfort. Additionally, in the practice of modern medicine the exact diagnosis of the etiology of abdominal pain is rarely made on physical examination.

• Advancement in technology and availability has made laboratory, x-ray, ultrasound, CT scan, & occasionally MRI essential in the diagnosis of abdominal pain.

• Therefore medication of abdominal pain is both humane and appropriate medical care.

• NOTE: Nitrous is not a good option for Abdominal Pain management

Chronic Pain

Chronic Painwww.webmd.com

• Defined as pain that lasts longer than six months. • Can be mild or excruciating, episodic or continuous, inconvenient or

incapacitating.• May originate with an initial trauma/injury or infection, or an ongoing

medical cause.• Or can have no cause at all• No past injury or illness

Patients With Chronic Pain• Higher rates of depression and anxiety.• Sleep disturbance and insomnia common.• Substance abuse highly prevalent in chronic pain

population.• Drug-seeking behaviors• Chicken or egg?

• Chronic pain may contribute to decreased physical activity.• Fear of making pain worse.

The Patient With Chronic Pain

Common Causes of Chronic Pain• Arthritis• Back Pain• Cancer• Chronic Fatigue Syndrome • Clinical depression • Fibromyalgia • Headache • Irritable Bowel Syndrome • Sciatica • Lumbar spinal stenosis and cervical spinal stenosis

Chronic Pain Treatmentsfrom National Institute of Neurological Disorders and Stroke

• Medications• Opioids• Benzo’s• Anti-depressants• Anti-Epileptics

• Acupuncture• Local electrical stimulation• Surgery• Placebos• Psychotherapy• Relaxation• Biofeedback

Chronic Pain and EMS

• Patients with chronic pain call EMS for many reasons• Pain recently got worse• Pain recently changed or moved• Pain now accompanied by new swelling, heat or deformity• Patient hopes EMS can provide pain medications that MD cannot or will not

(Pain contract)

EMS Treatment of Chronic Pain

• The EMS provider should remember that chronic pain is still a medical disorder• Not all in their head• Not all patients with chronic pain are drug-seekers• Not all patients with chronic pain are “whiners”

• Do not make light of their condition

Finishing up….

• Pain scale is a Vital Sign. • Pain has many causes, all real, just not all physical• Addressing all potential causes leads to more effective pain management.

• Pain management should be a part of initial patient care for extremity injuries.• Waiting to “get to the ambulance” for pain management is outside

the standard of care. Treat the “stable patient” where you find them. • Failure to give pain medication in the field may delay administration

for an hour or more in the hospital—proximity to the hospital should not prevent medicating.

Questions?