PAIN RELIEF IN PREHOSPITAL SETTING

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PAIN RELIEF IN PREHOSPITAL SETTING
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Why the pain relief is an emergency?

• protect the patient from suffer
• prevent secondary consequences

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the secondary consequences

• mental
• fear
• anxiety
• Panic
• autonomic nervous system
• sympathicotonic changes
• (sweating, pallor, BP?, HR?)
• increased pain threshold
• allodynia
• chronic pain

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ALWAYS SEARCH THE REASON OF THE PAIN

• Sometimes pain is a primary symptom
• Usually pain is a symptom of an underlying
  disease
• Pain as a leading symptom
• sudden beginning
• very powerful
• continual

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Modulation of pain

• Patients vary greatly in there reactions to pain
  depending on their emotional and social
  backgrounds
• Fear may aggravate the pain
• Patients who have never endured sickness seem
  more sensitive to pain than those who are more
  accustomed to it

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Attributes of the pain I.

• Provocative-palliative factors
• Association with bodily movement
• Association with respiratory motions
• Relief of chest pain by NG
• Relief of epigastric pain by antacids
• Localization
• Confined to one or more anatomic regions to which
  the patient can point
• Radiates to typical areas

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Attributes of the pain II.

• Intensity (severity)
• Patients descriptions (subjective)
• Examiners observations (objective?)
• facial expressions, bodily postures, reduced
  activity, sweating, pallor, dilatation of the
  pupils, elevated BP, HR
• Temporal characteristics
• Duration of the pain
• (remissions, constant pain, seasonal pain,
  daytime pain, nighttime pain)
• Increasing

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Attributes of the pain III.

• Quality (character)
• inflammation
• spasciticity
• ischemic
• distention
• neuralgic

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The referring pain
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Acute Pain is a Warning Symptom of Underlying
Problems
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Pain as a symptom ofunderlying desease

• Traumatology
• treat them with analgesics, anesthesia - local or
  general
• contusion
• head
• thoraces
• abdomen
• fractures
• wounds
• Surgery
• before a sure diagnosis dont use opiates, treat
  with analgetics, spasmolytics
• ulcus ventriculi seu duodeni
• perforation
• bleeding
• hernia
• ileus

• Internal deseases
• analgesics - spasmolytics - opiates if
  necessary
• vascular
• ischemic
• embolic
• inflammation
• tumor
• Neurological deseases
• anticonvulsives - sedatives - analgetics
• neuralgias
• tigeminal
• glossopharyngeal
• postherpetic
• neuropathias
• alcoholic, diabetic
• ischemic
• pressure

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Headache

• with neurological symptoms
• elevated intracranial pressure
• cerebrovascular disaster
• with/without neurology
• paroxysmal
• migraine
• Horton
• trigeminus neuralgia
• tension
• medical diseases
• diabetes
• fever
• neurological diseases
• tumor
• inflammation

• with/without neurology
• environmental injury
• trauma
• sunstroke
• carbon monoxide
• poisons
• alcohol
• coffein
• nicotine
• others
• ophthalmology
• stomatology
• nose- ear- pharynx

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Tools

• Adequate special interventions
• careful mobilisation, careful extrication
• proper immobilisation of fractures
• cooling of burns
• Medications
• analgetics, adjuvants
• Opiates if necessery (and do not cover the signs)
• anaesthesia
• Atraumatic transport

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Requirements for analgetics in the field

• Quick action
• Safe
• Broad therapeutic range
• Mild side effects
• CNS
• respiratory
• cardiovascular
• Iv. administration facillity

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• Analgetics
• inhalation
• nitrogenoxyd (O2N2O 11)
• non steroid analgetics
• Paracetamol (po.)
• Aspirin (po.)
• Novamidozophen Algopyrin (iv.) 25-30 mg/kg
• opiates
• Morphine deviates
• Tramadol (Contramal) 50-100mg

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Adjuvants

• Sedatives
• Diazepam (5-10mg)
• chlorpromazine
• midazolam
• Anticonvulsives
• carbamapezine
• phenotyon etc..

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Opiates derivativesPotent central acting
agents causing pain relief, sedative, hypnotic
effects, euphoria

• Indications
• AMI
• pulm.embolism
• arterial embolism in the extremities
• fracture of large bones
• dislocation of hip joint
• Contraindications
• craniocerebral injuries
• thoracic trauma (resp.insuff.)
• alcoholic condition
• acute abdominal pain

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Opiates derivatives

• Side-effects
• respiratory depression
• cradiovascular depression
• sphincter spasm (Oddi urinary bladder)
• Nausea/vomiting
• Medicaments
• morphine in small fractions
• 2-4-10 mg iv.
• petidine HCL in small fractions
• 10-100 mg iv.
• competitive antagonist Naloxon 0.4-0.8 mg iv.

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• Local anaesthesia
• infiltration anaesthesia
• regional nerve blockade
• Indications
• Fracture of the ribs
• Lumboischialgia
• take care of sterility
• lidocaine (1-2)
• 10-20 ml
• 1 hour

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Anaesthesia in the field

• Emergency anaesth. high risk intervention!
• Indications
• Extrication
• Any intervention causing pain (cardioversio)
• Any intervention if necessery (early intubation,
  ventillation, status epilepticus, status
  asthmaticus, tetanus)
• Contraindications
• Hypersensitivity to the anaesthetics
• Lack of necessary equipments and knowledge

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Anaesthesia in the field

• Strong indication
• Consent of the patient
• Necessary equipments and knowledge
• Have an open vein, and a proper anaesthetics
• Have monitoring facility (pulsoxymeter)
• You are able to intubate ventilate
• You know all the possible complications and can
  solve them
• give antiemetics as praemedication
• Documentation

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• Ketamin (in subanaesthetic dose for pain relief)
• iv.2.0 - 2.5 mg/kg 10-15 min anaesth. (for 10-15
  min)
• iv.0.25-0.5 mg/kg 5-10 min analg.
• im. 0.5-1.0 mg/kg 30-60 min analg.
• maintaince dose half of initial dose
• need sedatives (diazepam), because of the
  psychomimetic side effects (hallucination)
• cardiovascular stimulation (CO ? , HR ? BP ? )
• no respiratory depression
• bronchodilator
• !Increases IC, and intraocular pressure
• contraindications CNS injury, epilepsy,
  hypertension, cardiac insufficiency, glaucoma,
  perforated injury to the eyes

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• Propofol (Diprivan)
• dose 1.5-2.5 mg/kg bolus (for 2-8min)
• maintaince dose 25-50 mg bolus or 4-12 mg/kg/h
• The patient needs analgetics too
• cardiovascular depression (BP?)
• respiratory depression (apnoe)
• decreases intracranial pressure (ICP?)
• Etomidate