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This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Pre Hospital Analgesia

Post your experience

Whilst 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. A Health Care Commission survey of ambulance patients in 2004 revealed 20% of patients felt that more could have been done to manage their pain.¹ This stems from:

Concerns about patient honesty in evaluating the severity of pain.²
Concern that it may interfere with treatment necessary after admission.
Not having appropriate treatments available.³

Children are most often neglected, with significant disparities in perception of pain, and frequency that analgesia is given. Documentation of assessment and treatment given is often sporadic.⁴ Non-pharmacological methods of analgesia particularly useful in trauma, such as empathy, ice-packs, elevation, immobilisation and splinting should not be forgotten.

Immediate management

Condition	Recommended treatment⁵
Spinal cord compression	High dose corticosteroid. Ideally dexamethasone 15-16 mg intravenously.
Colic	Hyoscine butylbromide 20 mg subcutaneously, intramuscularly or intravenously.
Other severe pain	If not already receiving opiate give 5 mg diamorphine ( 2.5 mg in elderly) If already on morphine, calculate 4 hourly dose and give quivalent parenterally. Equivalent subcutaneous dose of morphine is HALF the oral dose.

Immediate pain management in adult trauma⁶

Pre-hospital care is a fast developing subspeciality. The British Association of Immediate Care (BASIC)⁷ provide training for any who feel they could benefit. Virtually all patients complaining of moderate to severe pain are candidates for pain management. The Ambulance Service is currently switching from 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 analog 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: 2-5 mg every 5 minutes, titrated against pain. IM 5-10 mg. May repeat after 20 minutes. 20 mg maximum. 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 5mg.
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 trauma⁶

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 pre-school age children
Glasgow Coma Score of less than 12
Patients taking monoamine oxidase inhibitors
Phaeochromocytoma
Previous anaphylactic reaction to morphine

Morphine doses for children⁸

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 mcg per kg every 4 hours, titrated against pain. e.g. 20 kg child dose = 4-8 mg.
Intravenous morphine sulphate	50- 100 mcg per kg, titrated against pain, as stat dose
naloxone	4 mcg/ kg, titrated against respiratory rate

Document references

Ambulance services survey, Healthcare Commission (2004)
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]
Regnard, C. and Hockley, J.(Eds)(2004a) A guide to symptom relief in palliative care.5th edn. Oxford:Radcliffe Medical Press.
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

Palliative care - oral problems, Clinical Knowledge Summaries (2007)

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 2008.
DocID: 394
Document Version: 2
DocRef: bgp1986
Last Updated: 16 Nov 2007
Review Date: 15 Nov 2009

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

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