2-20 PAIN MANAGEMENT

Purpose: To ensure that pain and nausea are appropriately addressed in the field to promote safe and comfortable management and transport of the patient.

Inclusion Criteria without prior Medical Control Authorization:

1. Musculoskeletal injury
2. Burns
3. Chest Pain
4. Abdominal or flank pain
5. Age greater than 6
6. Systolic BP > 100 mm Hg in an adult
7. Now known allergies to medications being administered
8. No known exclusion criteria present

Inclusion Criteria that require Medical Control contact prior to medication administration:

1. Pregnancy
2. Age <6 (may require dosage adjustment)
3. Weight <20 kg (may require dosage adjustment)

Exclusion Criteria:

1. Known allergy to medication
2. Respiratory distress with potential for patient fatigue
3. Systolic BP < 100 mm Hg
4. Altered Mental Status
5. Multi System Trauma

Protocol:

Intermediate - Perform/Confirm All Above Interventions

1. Obtain vital signs and allergies
2. Ask patient to rate pain on scale of 1 to 10
3. Establish an IV of NS TKO
4. If patient indicates a pain scale of greater than 5 and has no signs of poor perfusion or respiratory depression:
   1. For patients 6-75 years old: Administer fentanyl (Sublimaze) 0.5-1 mcg/kg INTRANASAL/INTRAMUSCULAR or mixed in 5 mL normal saline and given IV/IO push over 2-4 minutes to a maximum single dose of 100 mcg IV/IO. Reassess patient vital signs and pain scale after 5 minutes.
   2. For patients > 75 years old: Administer fentanyl (Sublimaze) 0.5 mcg/kg INTRANASAL/INTRAMUSCULAR or mixed in 5 mL normal saline and given IV/IO push over 2-4 minutes to a maximum single dose of 100 mcg IV/IO. Reassess patient vital signs and pain scale after 5 minutes.
5. Reassess pain scale and vital signs including pulse oximetry every 5 minutes
6. If sufficient pain relief is not obtained with the initial dose, then an additional dose of fentanyl (Sublimaze) 0.5 mcg/kg may be administered IV, IN, IM, or IO provided systolic BP remains above 100 mm Hg for a total max dose of 150 mcg
7. Ondansetron (Zofran) 4 mg IV or IN may be administered for control of patient nausea as needed with or without pain medication. Consult Medical Control for further doses of Zofran if sufficient relief is not obtained.

Paramedic - Perform/Confirm All Above Interventions

1. If FENTANYL has been administered and 5 minutes have passed without desired effect, or if there is a contraindication for administration of FENTANYL (signs of poor perfusion or respiratory depression), Contact MEDICAL CONTROL for consideration of administration of KETAMINE.
   1. If KETAMINE is administered after FENTANYL, the initial recommended dose of KETAMINE is 0.5mg/kg IV/IN/IO or 2mg/kg IM
   2. If KETAMINE is administered and there are any signs of emergence phenomena, such as hallucinations, delirium, or increasing agitation, contact medical control for discussion of supplemental Versed.
2. Initiate transport and Contact MEDICAL CONTROL for further orders.
3. Reassess vital signs, mental status, pain level and respiratory effort and if continued pain over 5, Contact MEDICAL CONTROL for any further dosages.