Pain Management

The protocol for Pain Management:

Pain Management

 

Let’s break it down!

---

---

The Pain Management protocol is one of the most frequently utilized protocols in clinical care. In it, there are 3 basic groups of medications: 

1. Tylenol
2. NSAIDS
3. Opiates

This step-wise approach is similar to the pain management guidelines in TCCC. For comparision, here’s a summary of the 3-option approach from the TCCC guidelines:

There are a few subtle differences noted in this protocol.

 

---

---

The first, and easiest pain-relieving medication we can give our patients is Acetaminophen

Acetaminophen works by inhibiting prostaglandins, which are chemical messengers throughout the body that travel to the central nervous system in the brain to let it know that it should be in pain.  By inhibiting their production after an injury, we are essentially tricking the brain into the thinking that no injury has occurred.  It also acts on the hypothalamus (the thermometer of the body) and helps reduce any fever

It’s rated as an analgesic (pain reliever) and an antipyretic (fever reducer), but it is NOT an anti-inflammatory.  This is super important because if someone comes into your aid station with pain from an inflammatory process (ex. sprained ankle), then this drug isn’t going to work as well as we want it to

It has very little effect on the platelet aggregation, so we don’t need to worry about giving this to patients with any potential bleeds.  It’s also not quite so harsh on the stomach like NSAIDS are, so you don’t really need to worry about telling patients to take it with food

Some soldiers may have allergies or sensitivities to Acetaminophen that you may want to ask about it, but in general, you don’t need to worry too much about the side effects so long as they take the recommended dose like they’re supposed to.  However, if they take more than 7,000mg per day (4,000mg is the daily limit), then it can cause enough damage to their liver to kill them.  Never ever ever EVER take acetaminophen with alcohol.

 

 

 

 

 

 

 

 

 

 

 

 

 

---

---

NSAIDs work sort of in the same way that acetaminophen does in that they also inhibit prostaglandin production, but they do so by directly inhibiting cyclooxygenase (COX) enzymes, which produce prostaglandins

Like Acetaminophen, NSAIDS are rated as analgesics (pain relievers) and antipyretics (fever reducers), but ALSO as anti-inflammatories due to the direct effect on both COX-1 and COX-2 enzymes

In general, there are more side effects associated with NSAIDs.  The big ones that you need to know though is that some NSAIDS can degrade the lining of the stomach.  In addition, they can inhibit platelet function, so typically you won’t want to give NSAIDS to someone who has any active bleeding (there are exceptions though… ex. Meloxicam in TCCC)

Meloxicam (Mobic) 

• Prescription based, not over the counter
• Longer duration than ibuprofen (only needs to be taken once per day) 🕑
• Known as a “selective NSAID”, which means that it only inhibits the COX-2 enzyme.  This is advantageous because it means that Meloxicam won’t alter blood clotting mechanisms (see why they recommend it in TCCC?).  It’s also supposed to be less harsh on the stomach, although some studies have proven otherwise

 

 

 

 

•  

 

 

Ibuprofen (Advil/Motrin) 

• Over the counter medication
• Needs to be re-dosed throughout the day 
• Known as a “non-selective NSAID”, so it inhibits both COX-1 and COX-2 enzymes, making it no so great for TCCC 
•  

 

 

 

 

 

 

Ketorolac (Toradol) 

• Very potent NSAID; works faster and stronger than the others (typically used after surgeries for moderate-severe pain) 
• Available in PO/IV form, but primarily used in the form of IM administration (makes it a good analgesic option for non-PO patients) 
• Also a “non-selective NSAID” so it’s a no-no for TCCC.  In addition, some studies have shown that Ketorolac can inhibit bone regrowth, making it a poor analgesic option following bone fractures.  However, this is controversial and still being studied
•  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

---

---

Opiates work by binding to opiate receptors that are found along with the central nervous system (brain, spinal cord, etc.) and essentially “numbing” them by keeping nociceptor pain signals from reaching the brain.  In addition to blocking these pain signals, it also causes flooding of dopamine into the brain causing a “euphoric” feeling and even works on the limbic system to alter your emotional response to the pain. In sum, they numb the pain and make you feel jolly 

There are a number of downsides to opiates though.  Since it’s depressing the central nervous system, that means it’s also depressing the soldier’s ability to spontaneously breath.  That’s why opiates are generally referred to as respiratory depressants.  In addition, you have opiate receptors in other parts of your body, such as your GI tract.  This can cause some pretty bad nausea/vomiting, as well as some terrible constipation.  Lastly, they’re highly addictive, even when used sparingly.

Morphine

• It’s a “natural” form of opium
• Slower onset than fentanyl, but lasts much longer 
• It causes a histamine release, which makes it more likely to cause hypotension (drop in blood pressure) and nausea/vomiting.
• Can also be given IO/IM/IN, and even PO, but mostly beneficial as IV in this setting
•  

 

 

 

 

 

Fentanyl

• It’s “synthetic” form of opium 
• Faster onset, but doesn’t last as long 
• 100X more potent than morphine (which is why it’s dosed in micrograms, not milligrams)
• Causes less of a histamine release, making it less likely to decrease blood pressure or cause nausea/vomiting 
• It can also be given IV/IO/IM/IN, but the lozenges are nice because they last a very long time.  The typical IV dose for Fentanyl would be approximately 50-100mcg.  The lozenges have up to 800mcg in them and it’s being administered slowly through the transmucosal route.  Granted, the bioavailability is only 50% so the true dose being received is only 400mcg….but that’s still a lot!  It’ll last a while! 
•  

 

 

 

 

 

 

 

 

 

 

 

 

 

---

---

 

---

---

Remember: Pain is a symptom of a problem, not the problem itself (in most cases).  This protocol will almost always be used in conjunction with another protocol (ex. headache, renal colic, etc.) that takes more precedence.  Those other protocols will be what determines your disposition.  And of course, if you’re ever giving narcotic medications to a patient, that should be a big whopping red flag that says don’t just send this patient home!

 

Till Next Time!

References

• Stapczynski JS, Tintinalli JE. Tintinallis Emergency Medicine: a Comprehensive Study Guide, 8th Edition. New York: McGraw-Hill Education; 2016.
• Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.
• NSAIDs VMC
• Acute Pain Management in the ED