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<< Pain Management in the Emergency Department

Prehospital Care

There is very little in the literature on pain control in the prehospital setting. A Pubmed search simply for the terms prehospital and pain only returned 293 English language articles since 1974. Very few of these articles were on the subject of pain control. Authors agree that pain is an important issue in the prehospital arena and that it is largely overlooked. Mclean made a conservative estimate that 20% of patients transported by EMS had moderate to severe pain. 46 Prehospital care is an important window during which pain should be assessed and treated. When prehospital care has focused on pain control, patients have had a significant reduction in time to pain relief. 47 Yet, there can be significant hesitation in giving prehospital analgesia. One study found that patients with femoral neck fractures were not likely to receive any analgesia, even
when requested. 48

There is disagreement as to whether or not children are less likely to receive prehospital analgesia, although no one argues the need for improvement in this population. A retrospective study in 2005 found that children and adults were equally likely (or unlikely) to receive prehospital analgesia for lower extremity fractures, and both groups had better rates of treatment in the ED. 49 However, a second study found children were less likely than adults to receive prehospital treatment, 50 and a New Zealand study reported that younger children are even more at risk for under-treatment. 51

With much room for improvement, even simple interventions have been beneficial for patients. An educational intervention in Chicago was productive in raising awareness of pain, as measured by improved documentation amongst paramedics. 52 Simple non-pharmacologic interventions may be useful. Active warming has reducedthe discomfort of back pain during transportation without the risks or complications of medical intervention. 53 Since EMS crews vary in their level of training by location, non-pharmacologic interventions have the advantage of being easier to implement across systems.

With regard to pharmacologic intervention, most studies have focused on the roles of morphine, fentanyl, and nitrous oxide. A retrospective chart review of 2129 patients from Colorado found that fentanyl was safe and effective in the field. 54 However, the novelty of use by paramedics, the difficulty of broad implementation, the relationship between EMS crews and medical control, and expense will vary across systems and may be logistically difficult to duplicate. In addition, since morphine and fentanyl are equally efficacious in the treatment of pain, 55 the cost of fentanyl over morphine would not outweigh the benefit in most prehospital settings.

Since the 1980s, authors advocated the use of 50% nitrous oxide by first responders as a safe and effective option for pain control when IV opiates are not an option. A few reviews and editorials have continued to advocate its use, but there are no current studies that assess its availability or breadth of use. 56-58