HEMS Medical Procedures: Pain Management (PDF)

HEMS Medical Control Authority PROCEDURES PAIN MANAGEMENT Initial Date: 6/13/24 Revised Date: Section 7-13...

HEMS Medical Control Authority PROCEDURES PAIN MANAGEMENT Initial Date: 6/13/24 Revised Date: Section 7-13 Pain Management Aliases: Analgesia, pain control, acute pain For patients with suspected cardiac chest pain, refer to the Chest Pain/Acute Coronary Syndrome-Treatment Protocol. The goal is to reduce the level of pain for patients in the pre-hospital setting. All pain should be assessed and scored according to the “Wong Pain Scale”. Reassessment should be timed according to medication onset of action, changes in patient condition, patient positioning and other treatments. Pain treatment should be based on pain scale but may need modification based on patient assessment or condition being treated. Wong Pain Scale: Pain Assessment Scale Choose a number from 1 to 10 that best describes your pain No pain Minor pain Moderate pain Severe pain 0 1 2 3 4 5 6 7 8 9 10 NO HURT HURTS HURTS HURTS HURTS HURTS LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST Feeling Nagging, annoying, Interferes significantly Disabling, unable to perform perfectly but doesn’t interfere with daily living activities. living activities. Unable to normal with most daily Requires lifestyle changes engage in normal activities. living activities. but patient remains Patient is disabled and unable independent. Patient unable to function independently. to adapt to pain. Note: Medical Control contact is required for patients with labor pains, established care plans that deter opioid pain management, or have established pain management care plans., 1. Place the patient in the position of comfort. 2. Pediatric patients (< 14 years) utilize MI MEDIC cards for appropriate medication dosage. When unavailable utilize pediatric dosing listed within protocol 3. Verbally reassure the patient to control anxiety. MCA Name: HEMS,Inc (WW/DR) MCA Board Approval Date:6/13/2024 Page 1 of 5 MDHHS Approval: 7/16/24 MCA Implementation Date: 8/1/2024  HEMS Medical Control Authority PROCEDURES PAIN MANAGEMENT Initial Date: 6/13/24 Revised Date: Section 7-13 4. Administer BLS interventions per applicable protocol (e.g., positioning, splinting, ice, etc.) 5. If not improved with BLS intervention, consider analgesia. 6. Start an IV if required for medication administration or per applicable treatment protocol being followed. 7.23 Vascular Access & IV Fluid Therapy-Procedure Protocol. 7. Per MCA selection, for mild to moderate pain (described as 1-6 on the Wong Pain Scale), consider non-opioid analgesia. MCA Selected Non-Opioid Analgesia (MCA must select at least one) ☒ Acetaminophen: 1. Adults (patients > 14 years of age), administer 650 mg PO 2. Pediatrics refer to MI MEDIC cards. When MI MEDIC cards are unavailable refer to dosing table below. ☐ Ibuprofen 1. Adults (patients > 14 years of age), administer 400 mg. a. Do NOT use in pregnant patients. 2. Pediatrics (patients > 6 months of age and < 14 years of age), refer to MI MEDIC cards. When MI MEDIC cards are unavailable refer to dosing table below. ☒ Ketorolac (Toradol ®) 1. Adults (patients >14 years of age), administer 15 mg IM/IV a. Do NOT use in pregnant patients 2. Pediatrics (patients > 5 years of age and < 14 years of age refer to MI MEDIC cards. When MI MEDIC cards are unavailable: a. administer 1 mg/kg IM/IV (max dose 15 mg) MCA Name: HEMS,Inc (WW/DR) MCA Board Approval Date:6/13/2024 Page 2 of 5 MDHHS Approval: 7/16/24 MCA Implementation Date: 8/1/2024  HEMS Medical Control Authority PROCEDURES PAIN MANAGEMENT Initial Date: 6/13/24 Revised Date: Section 7-13 Children’s Elixir Dosing Table Child’s Weight Child’s Age Acetaminophen Ibuprofen 160 mg/5mL 100 mg/5mL 3-5 kg (6-12 lbs.) 0-2 mos. 1.25 mL (40 mg) DO NOT GIVE 6-7 kg (13-16 lbs.) 3-6 mos. 3 mL (96 mg) DO NOT GIVE 8-9 kg (17-20 lbs.) 7-10 mos. 4 mL (128 mg) 4 mL (80 mg) 10-11 kg (21-25 lbs.) 11-18 mos. 5 mL (160 mg) 5 mL (100 mg) 12-14 kg (26-31 lbs.) 19 mos.-35 mos. 6 mL (192 mg) 6 mL (120 mg) 15-18 kg (32-40 lbs.) 3-4 yrs. 7 mL (224 mg) 7.5 mL (150 mg) 19-23 kg (41-51 lbs.) 5-6 yrs. 9 mL (288 mg) 9.5 mL (190 mg) 24-29 kg (52-64 lbs.) 7-9 yrs. 12 mL (384 mg) 13 mL (260 mg) 30-36 kg (65-79 lbs.) 10-14 yrs. 15 mL (480 mg) 15 mL (300 mg) 8. For patients with suspected kidney stone pain of any score, ketorolac should be considered first line if available. 9. For patients with severe pain (described as 7 or greater on the Wong Pain Scale), consider ketamine if applicable per MCA selection. MCA Selection for ketamine use in pain management ☐ Ketamine not permitted. ☐ Contact Medical Control prior to ketamine administration ☒ Administer ketamine 10. Ketamine may be administered IV/IO/IN as outlined below. a. Ketamine for pain management given IV/IO should be diluted. i. Dilution: the patient specific dose mixed with 100 ml NS and administer via slow infusion over 5-10 minutes to avoid dissociation symptoms. b. Administer ketamine IV/IO/IN i. Adults (patients > 14 years of age) 1. 0.2 mg/kg IV/IO (diluted) maximum single dose 25 mg 2. 0.5 mg/kg IN (undiluted) maximum single dose 50 mg 3. May repeat after 10 minutes. ii. Pediatrics (> 6 years of age and < 14 years of age) refer to MI MEDIC cards. If MI MEDIC cards are unavailable, follow below. 1. 0.2 mg/kg IV/IO (diluted) maximum single dose 7.2 mg 2. 0.5 mg/kg IN (undiluted) maximum single dose 18 mg 3. May repeat after 10 minutes. MCA Name: HEMS,Inc (WW/DR) MCA Board Approval Date:6/13/2024 Page 3 of 5 MDHHS Approval: 7/16/24 MCA Implementation Date: 8/1/2024  HEMS Medical Control Authority PROCEDURES PAIN MANAGEMENT Initial Date: 6/13/24 Revised Date: Section 7-13 iii. Pediatrics (> 6 months of age and < 6 years of age) refer to MI MEDIC cards. If MI MEDIC cards are unavailable, follow below. 1. 0.5 mg/kg IN (undiluted) maximum single dose 18 mg 2. May repeat after 10 minutes unless #11 applies below. 11. For patients with refractory pain after initial ketamine administration, a single dose of opioid medication may be given in lieu of the repeat ketamine dose. a. For additional doses of ketamine or opioid medication, contact on-line medical control direction. 12. If a patient is unable to tolerate ketamine or ketamine is not available and the patient has significant pain (described as 7 or greater on the Wong Pain Scale), opioid analgesia may be administered per MCA selection. a. Patients should receive only one opioid medication. b. If an IV is not available a single dose of opioid may be given IM. c. Do not administer additional pain medications after IM administration without on-line medical direction. MCA Selected Opioid Analgesia (Must select at least one) ☒ Morphine 1. Adults (patients > 14 years of age), administer 0.1 mg/kg IV/IO (maximum single dose 5 mg). May repeat three times. Total dose may not exceed 20 mg. 2. Pediatrics (patients > 18 months of age and < 14 years of age), refer to MI MEDIC cards. When MI MEDIC cards are unavailable administer: a. 0.1 mg/kg IV/IO (maximum single dose 5 mg). May repeat three times. Total dose may not exceed 20 mg. 3. Do NOT administer Morphine to children < 18 months of age. ☒ Fentanyl 1. Adults (patients > 14 years of age and < 65 years of age) administer 1 mcg/kg IV/IO/IN, rounded to the nearest dose 25, 50, 75, or 100 mcg, max single dose 100 mcg, may repeat one time. Total dose may not exceed 200 mcg. 2. Adults > 65 years of age administer 0.5 mcg/kg IV/IO/IN, rounded to the nearest dose 25, 50 mcg, max single dose 50 mcg, may repeat every 10 minutes up to three times (for a total of four doses). Total dose may not exceed 200 mcg. 3. Pediatrics (patients < 14 years of age), refer to MI MEDIC cards. When MI MEDIC cards are unavailable administer: a. 1 mcg/kg IV/IO/IN If an IV is not available a single dose of opioid may be given IM. DO NOT ADMINISTER ADDITIONAL PAIN MEDICATIONS after IM administration without on- line medical direction. MCA Name: HEMS,Inc (WW/DR) MCA Board Approval Date:6/13/2024 Page 4 of 5 MDHHS Approval: 7/16/24 MCA Implementation Date: 8/1/2024  HEMS Medical Control Authority PROCEDURES PAIN MANAGEMENT Initial Date: 6/13/24 Revised Date: Section 7-13 13. Administer opioids slowly when using IV or IO routes. Systolic BP should be maintained at >100 mm Hg for adult patients and > 80 + (2 x age) mm Hg for pediatric patients. 14. If nausea develops with pain medication administration, refer to Nausea and Vomiting-Treatment Protocol 15. For patients with evidence of hypotension or hypoperfusion, contact Medical Control Medication References Acetaminophen Fentanyl Ibuprofen Ketamine Ketorolac Morphine Protocol Source/Reference: OCMCA 7.13 Pain Management (Initial 2/2/2024: MDHHS Approved 4/26/24) MCA Name: HEMS,Inc (WW/DR) MCA Board Approval Date:6/13/2024 Page 5 of 5 MDHHS Approval: 7/16/24 MCA Implementation Date: 8/1/2024