Pain Control Protocol PDF

MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Pain Control Protocol Tier II & Tier III Pain, and the lack of relief from the pain, is the most common complaint among patients. P...

MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Pain Control Protocol Tier II & Tier III Pain, and the lack of relief from the pain, is the most common complaint among patients. Pain control can reduce the patient’s anxiety and discomfort, making patient care easier. The patient’s severity of pain must be properly assessed in order to provide appropriate relief. Managing pain clinically in the inter facility setting will provide greater patient care. Special attention must be paid to this as the patient is being taken from the controlled environment of the transferring facility to the mobile environment involving multiple moves and transport. Assessment 1. Assess level of pain using the Pain Assessment Scale (0-10) or the Wong-Baker Faces Pain Rating Scale. 2. Place patient in a position of comfort if at all possible. 3. Reassure the patient. Treatment and Interventions 1. Consider ice or splinting. 2. Reassess level of pain using the approved pain scale. 3. Care should also focus on the pharmaceutical management of pain. 4. Pain medication can be given in situations where the patient still requires additional doses and the systolic BP > 90mmHg. 5. IVP medications can include a) Morphine Sulfate: 2-5mg IV every 5 minutes to reduce the patient’s anxiety and severity of pain. If unable to establish IV access, may administer Morphine 2-5mg IM every 15 minutes. b) Ondansetron (Zofran): 4mg IV over 2 minutes or IM for nausea and/or vomiting. May repeat in 15 minutes with additional 4 mg IV. c) If the patient is allergic to Morphine or if Morphine is not effective: d) Fentanyl: 50mcg IV over 2 minutes for pain. Fentanyl 50mcg IV may be repeated one time in 5 minutes to a total of 100mcg. If unable to establish IV access, may administer Fentanyl 50 mcg IM. May be repeated one time in 15 minutes to a total of 100mcg. e) Hydromorphone: 0.5mg-1mg IV. This may be repeated only once total. f) Ketamine: 30 mg IV (patients over age 15 only) after initial Opioid administration. May repeat in 15 minutes. 9. Narcan 2.0 mg IV/ IN should be available at all times. 10. Contact Medical Control if prolonged transport and have maxed out narcotic dose on protocol. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.D.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Pain Control Protocol (continued) Wong-Baker Faces Pain Rating Scale Pearls Monitor the patient for respiratory depression when administering narcotics. Blood pressure should be monitored closely – check 5 minutes after narcotic administration (and prior to administering repeat doses). Verify that the patient is not allergic to the pharmaceutical agent prior to administration. Patients with a head injury / ALOC or patients with unstable vital signs should not receive pain medications without direct order from Medical Control. In patients with known renal failure, the Fentanyl dose must be reduced to 25mcg. The dose may be repeated one time to a maximum dose of 50mcg. Lidocaine: 30mg IO (slowly) to reduce discomfort from infusion may be given IO to conscious patients experiencing discomfort from IO infusion. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.D.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Patient Sedation Protocol Tier II & Tier III Situations will exist where safe management and transportation of the patient will require sedation of the patient. This could be to prevent the patient from further injuring themselves during transport or to support the sedation needed for airway maintenance. Assessment 1. Assess for any causes of anxiety, confusion or other conditions that can be corrected. 2. Attempt verbal reassurance to calm patient. 3. Ensure that the patient can be safely transported by the CCT. a. If uncertain the CCT can safely transport the patient, seek restraint order for transport. Treatment and Interventions- Sedation 1. Midazolam: 2.5-5mg IV/IN/IM to reduce the patient’s anxiety. May repeat in 5 minutes if needed. If giving IV, give slowly over 2 minutes. Watch respiratory status and have bag valve mask ready. 2. Lorazepam: 1-4 mg IV. May repeat every 15 minutes. 3. Diazepam: 2-10 mg IV/IM. May repeat every 10 minutes. Treatment and Interventions- Sedation of the Intubated Patient 1. Propofol: Continue IV infusion established at transferring facility. Infusion can be increased by 5-10 mcg/kg/min every 5-10 minutes until desired sedation is achieved. Infusion rate parameters are 5-55mcg/kg/min. 2. Midazolam: 2.5-5mg IV/IN/IM to reduce the patient’s anxiety. May repeat in 5 minutes if needed. If giving IV, give slowly over 2 minutes. 3. If paralytic is needed in addition to sedation (On Call Critical Care Medical Control must be contacted before paralytic is used) a. Rocuronium: 1 mg/kg or 100 mg (one time push) Onset 1-2 minutes. Treatment and Interventions- Excited Delirium 1. Use extreme caution to provide for crew safety. 2. Have restraints ready. Ensure you have enough providers to complete restraint procedure. 3. Ketamine: 1mg/kg IVP or 2 mg/kg IM. May repeat X 1 if necessary. 4. Prepare to provide airway and ventilatory support. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.E.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Use of Advanced Access Tier II & Tier III Patient’s with certain ongoing medical problems may have an Implanted Subcutaneous Port (ISP). If the port is accessed via steril technique by the transferring facility and not signs or infection or infiltration exist, the CCT crew can continue to use the port. If any concerns the crew should more to obtaining intraosseos access utilizing pain medications as needed. Tier III In certain situations the CCT team may be called to transport a patient who the transferring physician has inserted a central line. The transferring facility may or may not have accessed the line for medication/ fluid administration prior to arrival of the CCT team. Accessing Central Venous Catheters 1. Special attention should be paid to maintaining aseptic technique. 2. Wear clean gloves. 3. Scrub the injection cap (e.g., needleless connector) with an appropriate antiseptic (e.g., chlorhexidine, povidone iodine, or 70% alcohol), and allow to dry (if povidone iodine is used, it should dry for at least 2 minutes). 4. Access the injection cap with the syringe or IV tubing (opening the clamp, if necessary). Flushing Technique 1. Single-use flushing systems (e.g., single-dose vials, prefilled syringes) should be used. 2. Access the catheter as outlined above, maintaining aseptic technique. 3. Use a syring with size 10 mL or greater. 4. Flush the catheter vigorously using pulsating technique and maintain pressure at the end of the flush to prevent reflux. 5. Positive pressure technique (may not apply to neutral-displacement or positive- displacement needleless connectors): a. Flush the catheter, continue to hold the plunger of the syringe while closing the clamp on the catheter and then disconnect the syringe. b. For catheters without a clamp, withdraw the syringe as the last 0.5-1 mL of fluid is flushed. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.F.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Blood Administration Tier II & Tier III Severely ill of injured patients will greatly benefit from the administration of blood products as soon as they can be administered. Ideally, this would be started at the outlying hospital and continued by the CCT team. In some situations the blood products may not be available prior to the CCT team arrival. In such instance, initiation by the CCT team would be of great benefit to the patient. Assessment Patients who are candidates for blood product administration include 1. Adults who are, or suspected to have acute blood loss. 2. Are still considered unstable after administration of 2 liters Normal Saline. 3. SBP less the 90mmHg or other clinical signs of shock (AMS, tachycardia, pallor, delayed capillary refill, etc.) 4. Who have had 2 boluses of 20mL/kg without stabilizing of condition. 5. Other clinical signs of shock (AMS, tachycardia, pallor, delayed capillary refill, etc.) Prior to administration, and every 15 minutes afterward, the patient should be assessed for 1. Complete set of vital signs, including temperature 2. Skin condition 3. Lung sounds 4. Previous transfusion history 5. Current fluid resuscitation status 6. IV site 7. Adults 18ga or larger (20ga if not infusing PRBCs) 8. IV site patency 9. IV site dedication as only being used for blood product administration 10. Include in the documentation any blood typing information obtained at the transferring facility. 11. If any blood products are being taken with patient, maintain products in cooler on ice for transport. Document time units were accessed from Blood Bank. If unused during transport, these should be turned in at receiving facility Blood Bank. Treatment and Interventions 1. Appropirate PPE should be worn by the CCT team member performing the intervention. Prior to any intervention, if patient condition allows, the procedure should be explained to the patient. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.G.1.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Blood Administration (continued) 2. Remove blood products from cooler. Verify temperature of 2-8 degrees Celcius. Once removed from 2-8 degree Celcius enviroment, products must be administered or discarded within four hours. 3. The following information must be confirmed by at least two health care providers a. Patient’s name (this could be a john or jane doe assignment) b. Patient’s blood type c. Type of blood products d. ABO type of blood products e. Unit number and expiration 4. The two health care providers who verified should sign all appropriate documentation. This should also include the time the infusion began. 5. Infusion rates vary 6. Begin at slower rate and closely monitor for signs of reaction. 7. Infusion can be sped up after no signs of reaction are seen 8. Blood products can be infused with the assistance of a pressure bag so long as the pressure in the bag does not exceed 300mmHg for adults. 9. If reaction is noted a. Immediately stop the transfusion b. Remove all tubing associated with the infusion from the patient c. Reassess patient. d. Treat any complaints of patient. e. Deliver all blood and delivery devices to receiving facility. 10. Blood products should be administered with a. 10 gttp Baxter Sigma Smart Pump tubing b. Leukocyte reduction filter c. Piggyback 1000 mL Normal Saline d. Rate based on transfer orders. e. Rate can be increased to wide open and pressure bag utilized if patient condition necessitates. 11. When infusion is complete, flush IV site with Normal Saline. 12. Document in the PCR a. Type of blood product b. Unit number c. Time transfusion was started and ended d. Total volume and rate infused e. Signs or lack of signs of reaction f. Complete vital signs at completion of transfusion Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.G.2.  MEMORIAL EMS SYSTEM CRITICAL CARE MANUAL Blood Administration (continued) 13. Consider a. Diphenhydramine: 25-50 mg IV/IM if signs of allergic reaction noted. b. Furosemide: 20 mg IV/IO after each unit for adult patients demostrating any signs of CHF. i. If patient with penetrating trauma < 3 hours since injury, and signs of hypovolemic shock see TXA Protocol. Controlled Copy– not for distribution beyond intended recipient; Intended recipients will be notified of updates after initial distribution 2.G.3.