Sign inWhilst awaiting transfer to secondary care it is good practice to manage pain effectively. There is well-documented evidence that we are reluctant to treat patients in this way.
This may stem from:
- Concerns about patient honesty in evaluating the severity of pain.1
- Concern that it may interfere with treatment necessary after admission.
- Not having appropriate treatments available.2
Children are most often neglected, with significant disparities in perception of pain, and in frequency that analgesia is given. Documentation of assessment and treatment given is often sporadic.3 Non-pharmacological methods of analgesia particularly useful in trauma (such as empathy, ice-packs, elevation, immobilisation and splinting) should not be forgotten.
Immediate pain management in adult trauma4
Pre-hospital care is a fast-developing subspeciality. The British Association for Immediate Care (BASIC) provides training for any who feel they could benefit.5 Virtually all patients complaining of moderate-to-severe pain are candidates for pain management. The Ambulance Service has switched from nalbuphine hydrochloride (Nubain®) to morphine sulphate as first-line management of severe pain. It is the analgesia of choice for myocardial infarction and severe trauma. Morphine is potent and should not be used indiscriminately. Entonox® is also available for moderate pain relief. This is contra-indicated in chest injury and head injury associated with reduced Glasgow Coma Scale.
General points:
- Monitor patient observations closely.
- Have naloxone to hand, in case of respiratory depression.
- Use visual analogue scales to document level of pain before and after treatment.
| Pain management criteria | Hospital contact | Treatment |
| Any patient complaining of: significant injury to extremities, burns, crush injury, prolonged extrication, severe back/spinal pain, immobilised patients, abdominal pain, journey time >10 minutes. | Not required. Unless more than 20 mg morphine sulphate required. | Oxygen. IV access. Morphine sulphate IV:
Medical cases respond well to smaller doses than trauma. |
| Critical trauma patients with: abdominal trauma or thoracic trauma. | Not needed unless more than 5 mg morphine sulphate required. | Oxygen. IV access. Morphine sulphate, IV or IM, titrated against pain to a maximum of 5 mg. |
| Other patients complaining of: head trauma, decreased respirations, altered mental state, women in labour, BP less than 90 systolic, journey time less than 10 minutes. | Required. | Contact base physician before giving ANY medication. |
Immediate pain management in paediatric trauma4
| Pain management criteria | Base contact required? | Recommended treatment |
| Any patient with significant injury to extremities, burns, crush injury, back or spinal pain, abdominal pain, immobilised patients, journey times greater than 10 minutes. | No. Unless greater than allowed maximum dose or morphine sulpahte is required. | Oxygen. IV access. Morphine sulphate as below. |
| Critical trauma patients including abdominal trauma, thoracic trauma or head trauma. decreased respirations, altered mental state, journey time less than 10 minutes, blood pressure outside normal range. | Yes. | Contact base physician before giving any treatment. |
Contra-indications for morphine use
- Infants less than 1 year old.
- Hypertensive patients; diastolic greater than 90 mm Hg adults, 80 mm Hg school children or 70 mm Hg preschool age children.
- Glasgow Coma Score of less than 12.
- Patients taking monoamine oxidase inhibitors.
- Phaeochromocytoma.
- Previous anaphylactic reaction to morphine.
Morphine doses for children6
Pain should be documented as a fraction, e.g. 3/10. Use visual scales according to age - i.e. happy/sad faces.
| Drug and route | Recommended dose |
| Oral morphine sulphate | 200-400 micrograms per kg every 4 hours, titrated against pain. e.g. 20 kg child dose = 4-8 mg. |
| Intravenous morphine sulphate | 50-100 micrograms per kg, titrated against pain, as stat dose. |
| Naloxone | 4 micrograms per kg, titrated against respiratory rate. |
Document references
- Jones GE, Machen I; Pre-hospital pain management: the paramedics' perspective.; Accid Emerg Nurs. 2003 Jul;11(3):166-72. [abstract]
- Spedding RL, Harley D, Dunn FJ, et al; Who gives pain relief to children?; J Accid Emerg Med. 1999 Jul;16(4):261-4. [abstract]
- Hennes H, Kim MK, Pirrallo RG; Prehospital pain management: a comparison of providers' perceptions and practices.; Prehosp Emerg Care. 2005 Jan-Mar;9(1):32-9. [abstract]
- UK Ambulance Service Clinical Practice Guidelines, Joint Royal Colleges Ambulance Liaison Committee (2006)
- BASICS; British Association for Immediate Care (website); A source of training for those interested in providing pre-hospital care.
- UCL Paediatric Analgesia
Internet and further reading
- Thomas SH, Shewakramani S; Prehospital trauma analgesia. J Emerg Med. 2008 Jul;35(1):47-57. Epub 2007 Nov 9. [abstract]
Acknowledgements
EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2010.Document ID: 394
Document Version: 3
Document Reference: bgp1986
Last Updated: 22 Apr 2010