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Pain Relief Administration
There is more to basic pre-hospital and emergency first aid than basic life support.
The standard pre-hospital & emergency first aid treatment is focused on basic life support:
A – Airway
B – Breathing
C – Circulation
Basic emergency and pre-hospital treatment usually stops here, but one further element of patient care must be addressed, and that is pain management.
PAIN MANAGEMENT Pain management is the biggest unresolved issue in pre-hospital and emergency treatment. In the context of pre-hospital and emergency treatment. Pain relief must be:
Easy to administer
Storable in numbers, not deteriorate
Minimal side effects / no scope for abuse
Acceptable to patients
This set of attributes is difficult to satisfy, and is why pain management has been a major unresolved issue in pre-hospital and emergency treatment. When a casualty is injured, modern medicine states that a pain relief should be given.
Options for pre-hospital and emergency pain relief
There are a number of existing options for pre-hospital and emergency pain relief. Several options available for a first responder to provide for pain relief (for e.g. Methoxyflurane and Entonox, Aspirin or Paracetamol, Heat treatment e.g. for penetrating marine creature injuries, Ice e.g. for local skin pain etc.). The primary means for pain relief by the occupational first aid officer is to position the casualty or the injured body part in the most comfortable position according to the type of injury. However, if your company policy decides that a pain reliever can be given, it is usually one of either two alternatives, Penthrane or Entonox. In each case, the drug is meant for self-administration by a conscious, alert and spontaneously breathing casualty. If the rescuer is uncertain of the casualty’s conscious state or their ability to follow directions for use, then that rescuer should seek further advice.
Pre-hospital and emergency analgesic agents
Pain relief, including the use of pain relieving drugs (analgesics) plays an important part in preventing the casualty from deteriorating. Increasingly, in circumstances where injury is likely and pain will surely be a consequence, first aid equipment made available on site may now include analgesics. To be useful in a pre-hospital and emergency setting, analgesic agents must have a very rapid onset. Commonly used pre-hospital and emergency analgesic agents are: – Inhaled agents:
Entonox (50:50 nitrous oxide & oxygen)
Penthrane (Inhaled Methoxyflurane)
– Injected agents: (not covered in this course)
Opioids (i.e. Morphine)
Providing pain management
1. Identify need for analgesia
Identify the casualty's need for pain relief (see rating the casualty’s pain)
Consider the available options to relieve the casualty's pain. Where pain relief drugs are identified to be used:
Further emergency assistance must be obtained;
The appropriate drug must be obtained and checked;
Contraindications and precautions for use of analgesic drug must be identified; and Confirm the use of the drug is appropriate for casualty (allergies, history etc); and The appropriate dosage for casualty must be determined and confirmed (make sure they have not already taken the drug that day, read the dosage guides on the bottle or instruction pamphlet, use a self-doser).
2. Access and prepare analgesic
Follow the required standards, manufacturer’s guidelines, organisational protocols, permits for the use of restricted analgesic drugs, state/territory legislation and regulations etc. for preparation and use. The analgesic drug will be securely stored as per legislative requirements i.e. Therapeutic Goods Act and Regulations, WHS Act. Australian Standards relating to the storage and handling of gases in cylinders.
The identified drug must be accessed and brought to the casualty.
Confirm the correct drug has been retrieved and it is within its expiry date, and it has not been tampered with.
With the casualty - Calmly, with confidence, an in a reassuring manner, communicate to:
Ask for consent to assist, get them to confirm verbally or nod yes or no;
Provide comfort and first aid according to injury or illness; and
When the drug is available at the scene, explain the risks and purpose of the analgesic drug, and instruct the casualty in self-administration. With medical personnel on first contact and request assistance according to relevant circumstances – clearly and accurately state facts about location, incident and type of injury or illness, report the casualty condition. Listen to advice and instructions. With medical personnel on handover: Accurately, stating facts, report the casualty’s condition, details of the incident including analgesic drug administration and treatment provide
4. Administer analgesic
Analgesic drug is to be administered according to required standards and safety procedures i.e. the safety procedures for the operation of pressurised gases as relevant to available analgesics, follow medical gas protocols, read instructions and guidelines, follow safety precautions for use and environment, monitor at all times when in use, do not give more than prescribed amount etc.
Monitor the casualty continuously while administering analgesic drug – Assess vital signs such as level of consciousness, breathing rate, pulse rate, skin colour and temperature etc.
5. Perform casualty handover
Communicate with medical personnel on handover: Accurately, state facts, report the casualty’s condition, details of the incident including analgesic drug administration and treatment provided.
Note: this requirement is to ensure safety of the casualty – i.e. to avoid the paramedics or medial professionals giving more drugs and over dosing the casualty, to ensure appropriate follow up treatment, so the medical person taking over knows what the casualty has already taken, to be able to confidently provide further treatment etc.
6. Complete required documentation
Complete written records of the treatment, including analgesic drug and dosage and supply to medical personnel according to required standards.
Complete all other required documentation with all of the incident details such as casualty injuries, treatment provided, type, dosage and time of drugs administered. Forms and documentation might include:
Specific organisational first aid and drug administration forms
Incident report forms and logs
Treatment logs and report forms
Example of a sample drug register form:
Example of an incident
7. Complete analgesic use requirements
Disposal - Unused analgesic drugs must be disposed of in accordance with required standards, manufacturer’s guidelines, organisation policy and state legislation. As an example: a person must not discharge, dispose of or use a restricted drug in a way that:
(a) Endangers the life or safety of a person or domestic animal; or
(b) Exposes food, drink or a condiment or another drug or a poison to the risk of contamination by the drug; or
(c) Gives access to the restricted drug to someone not endorsed to possess it
Debriefing/evaluation – participate is a discussion with everyone involved in the incident and authorities, about the incident, for the purpose of evaluation to ensure correct steps were undertaken, to look for improvements, and to identify stress levels and emotional needs. Identify the need for further training i.e. to ensure skills and knowledge are kept current in accordance with state/territory regulatory requirements, ensure attendance of refresher courses, be aware of, and understand changes to legislation, policies, procedures and guidelines etc.
Patient Descriptions of Pain
Pain is described by persons experiencing it in words that relate to physical sensations, like "tingling" or "aching," and in emotional words, like "horrifying" or "terrifying." To illustrate pain, people often use vivid verbal pictures such as, "I feel like someone is stabbing me repeatedly and twisting the knife," or "My head is in a vice that is being squeezed tighter and tighter." Behavioural responses, including grimacing, bracing, or rubbing the affected area, are methods of communicating about painful sensations. These behaviours, and the accompanying signs of autonomic activation (e.g., tachycardia, tachypnea) are common in acute pain, but uncommon in chronic pain even in the presence of sig- nificant pain.
Physicians and treatment providers can feel challenged when called upon to evaluate and treat painful sensations and the suffering they evoke.
Types of Pain
Acute pain is pain that is the result of an injury or illness that is time- limited. Low back pain following an injury, acute headache, and postoperative pain are examples of acute pain. Acute pain is generally thought to have the biological function of alerting the individual to harm and preparing for the "fight-or-flight" response to danger. Diagnosing and treating the underlying cause of pain, in addition to treating the symptomatic pain, are the critical elements of pain management. Chronic pain is pain that persists and does not resolve spontaneously. Chronic pain has usually been defined arbitrarily as pain that persists for three to six months, or beyond the period of time that healing could be expected to have occurred (Jacobson & Mariano, 2001). Ongoing or progressive tissue damage may be present in some types of chronic pain, including progressive neuropathic pain and rheumatologic conditions. In other cases, chronic pain may be present when tissue damage is stable or undetectable.
Numerical Rating Scale
The numerical rating scale (N RS) is an 11-point scale on which patients rate the intensity of their pain by choosing a number from 0 (no pain) to 10 (pain as bad as it could be). This rating scale is commonly used and easy to understand. This scale has also been shown to be valid and reliable. It is suitable for use in adults and children over six years of age who have an understanding of the concepts of rank and order. Avoid using numbers on this scale to prevent the casualty receiving cues. Some casualties are unable to use this scale with only verbal instructions but may be able to look at a number scale and point to the number that describes the intensity of their pain.
What is the intensity of your pain right now?
0 1 2 3 4 5 6 7 8 9 1 0
No pain Pain as bad as it could be
Wong – Baker FACES Pain Rating Scale
This scale can be used with young children aged three years and older and may also be useful for adults and those from a non-English speaking background. Point to each face using the words provided to describe the pain intensity. Ask the child to choose face that best describes his/her own pain and record the appropriate number.
PAIN RELIEF USING ANALGESIC GASES
So why use analgesic gases?
Offer immediate pain relief
Have very few side effects
Are easy to use and are based on Casualty Self Administration
Have effects that wear off quickly post administration and can be used without complications with general anaesthetics if surgery is later required Allow for management of trauma causing pain with minimal discomfort to the casualty Offer pain and reduction combined with appropriate first aid management help promote recovery
There are two types of pain relief that will be covered in this course.
They are Penthrane and Entonox.
As both Penthrane and Entonox are registered drugs they have to be kept secured and a register of use must be maintained.
Be aware that either drug must be used on its own, no mix & match. There are also several contra-indications for use for both drugs.
Entonox is a homogeneous gas containing a mix of 50% oxygen and 50% nitrous oxide compressed into a cylinder similar to Oxygen.
It was introduced commercially in 1965 and is most commonly used as a method of pain control during labour and to control trauma related pain, both by paramedics and in accident and emergency departments. As well as providing analgesia Entonox can produce feelings of relaxation or euphoria, and is therefore also useful to relieve anxiety. Entonox is a potent analgesic with properties comparable to that of strong opioids. It can provide short-term pain relief, sedation and reduced anxiety during a wide range of painful procedures such as chest drain removal, pin site dressings, physiotherapy, and lumbar punctures. Nitrous oxide is an anaesthetic gas; hence misuse of Entonox could potentially result in loss of consciousness.
It requires regulators and apparatus to be delivered to the casualty. It is harder to track the use of Entonox, as an accurate calculation of the cylinder contents must be recorded. Due to the potential risk of loss of consciousness Entonox should be self- administered when used for procedural pain. The patient must therefore be able to cooperate by holding the demand valve and inhaling the gas himself/herself. If the patient is unable to do this alternative analgesia should be given.
Entonox is a known drug of addiction. It must be securely stored where ever it is located (vehicle, first aid facility etc.)
Health care professionals administering Entonox should be trained in its use and familiar with the side effects and contra-indications. Staff should also be aware that Entonox is a habit-forming drug and has been subject to abuse. Documented cases of abuse are rare, but addiction may result with long-term use and this can lead to myeloneuropathy and subacute combined degeneration.
A full report on its use must be forwarded to the Company Medical Officer through Head Office after its use.
Entonox should only be administered by personnel who are:
Competent in the administration of Entonox & basic life support.
Familiar with the side effects of Entonox & its contra-indications.
Aware of the criteria for patient selection and exclusion.
Trained in its use
Nitrous oxide (N 2 O) gas has been known to have analgesic and sedative properties for over two hundred years. The gas was discovered by a Yorkshire chemist named Joseph Priestly and in 1799 the scientist Humphry Davy inhaled the gas and found it gave him rapid pain relief from an infected tooth; on one occasion he reported momentarily losing consciousness, waking up laughing about the pleasurable feelings he had experienced: hence the term 'laughing gas'. As a medicinal gas, it is available as a mixture containing equal parts of N 2 O and oxygen (O 2 ). In many countries this is commercially available as Entonox, although it is also available as Kalinox in France or Medimix in Sweden. In the UK it is often known to patients and staff as 'gas and air' and since the 1960s has most frequently been associated with childbirth and use by ambulance crews.
Indications for use
Entonox is ideal in situations where pain is predictable and of a short duration. It can provide relief of pain during minor procedures such as wound dressing changes, debridement, the removal of drains or sutures and even turning a patient with a fracture or a pressure ulcer. In some circumstances the use of Entonox may aid the patient's ability to comply with lengthy or uncomfortable procedures, such as flexible sigmoidoscopy examination. All are situations where the medical personnel can instigate and supervise the use of this rapid action analgesic gas mixture.
Use in children
Entonox is safe for any age group as long as the patient is able to comprehend the activity and be physically capable of operating the system. The same cautions and care in use must therefore apply for all ages. Entonox is an excellent analgesic for children, providing pain relief, distraction and relaxation but preparation and training may need to be more sensitive and involve parents or carers. However, while parents or carers may support the child during the procedure they must not take over the positioning of the facemask. Younger children who are either unable to understand or handle the equipment may require assisted administration, but this is outside of the general scope of treatment is generally carried out by specially trained paediatric nurses.
Contraindications to the use of Entonox
Entonox will cause an enclosed air pocket in the body to expand rapidly in volume as the gas mixture is absorbed from the blood into the space, resulting in a build-up of pressure. It must therefore never be used if the patient has any conditions where air is trapped in the body and expansion would be dangerous; for example, it will exacerbate the onset and development of a pneumothorax (air inside the chest cavity but outside of the lung) and can increase the pressure of intracranial air following head trauma. Entonox can also be drawn into other cavities, such as the sinuses, middle ear and gut, causing expansion and pain. In such cases the patient should stop using the gas.
It is recommended that Entonox gas should not be used in the following situations:
Following a head injury where consciousness is impaired. However, for patients who require sutures to a head wound, the use of Entonox may be appropriate providing the patient is alert and able to follow simple commands. Such judgements regarding Entonox use should only be made by an experienced practitioner
Where there is artificial, spontaneous or traumatic pneumothorax
If there is an air embolism
In cases of decompression sickness
Where there is abdominal distension or suspected bowel obstruction
In maxillofacial injuries.
Repeated exposure to Entonox may result in megaloblastic anaemia owing to interference with the action of vitamin B12.
If a procedure is to be carried out more frequently than every four days, the patient should be monitored and a routine blood cell count carried out.
As the gas mixture is designed for short-term use only it should not be used in place of general continuing analgesia; for example in the case of burns or fractures, where an appropriate analgesic assessment is necessary for long-term management. It has been suggested that using Entonox for a short-duration but with repeated daily exposure in burns patients may increase the risk of developing megaloblastic anaemia and leukopenia in a group that invariably have blood abnormalities as a result of the tissue trauma and serus fluid loss following the burn damage.
Health and safety precautions
Prevention of accidental use: Entonox is supplied in blue cylinders with white shoulders. A unique pin-index valve port on the cylinder prevents the wrong type of gas cylinder from being connected to the Entonox regulator valve and tubing. Staff safety: Occasional patient supervision by staff should not subject them to any undue risks of prolonged exposure to Entonox, but frequent use in a treatment room should prompt management to provide a gas scavenging system or increased ventilation. Effects: Although Entonox is rapidly eliminated from the body, the British Oxygen Company (BOC) advises that patients should not drive or operate machinery for at least 12 hours. For patients having repeated procedures, where there has been time for individual assessment as to the duration of effect, a less strict regime may be appropriate.
Access and storage : It must be securely stored where ever it is located (vehicle, first aid facility etc.). Local policies should cover access to medical gas cylinders and ensure staff training in assembling the necessary components. Where necessary, this should also cover transportation of the systems. It is advisable to keep the cylinder away from the driver area, in case of a leak. The tubing should be disconnected and the cylinder turned off prior to starting a journey. It may also be worth checking with an employer about whether any additional insurance cover is required to carry Entonox. Handling: A person must not carry, handle or store a restricted drug in a way that may allow the drug to mix with, or contaminate, food, drink or a condiment or a drug or poison for human or animal use even if the container in which the drug is carried, handled or stored breaks or leaks.
The gas is administered using a face mask or mouthpiece; gas flow is controlled by a sensitive demand-valve activated by the patient's inspired breath.
This allows pressurised gas from the cylinder to flow through a pressure regulator into the lungs at a steady rate.
Longer and deeper breaths allow greater volumes of gas to be taken into the lungs if necessary.
The gas is rapidly absorbed on inhalation, providing analgesia within minutes. It is excreted, largely unchanged, by the lungs and its rapid elimination from the body on cessation of inhalation makes it ideal for controlling pain during short procedures.
The patient safely controls the dosage and, under normal conditions, there is no risk of overdose as the patient's level of consciousness governs his/her ability to maintain the flow of gas. With mobile equipment, Entonox can be used anywhere. This may be by a hospital bed or treatment room, or in the patient's own home. In each case the patient must be made comfortable, be assured of privacy, and be guaranteed a short period of rest following the procedure.
Protocol for administration
Entonox should be administered according to a locally agreed protocol following a period of instruction or training. The protocol should cover a number of key areas as follows: Assessment: Consider the need for Entonox during the planned procedure and whether other analgesics may be required. It is important to remember that oral analgesics can take some time to work and should be given in advance if they are to have any benefit in the immediate post-procedure phase when the gas has worn off. Entonox is not as effective as intravenous sedation and analgesia, for example midazolam plus an opioid such as fentanyl, but it is simpler to administer, wears off more quickly and is potentially safer. Entonox should not be used as a substitute for general anaesthesia or more profound supervised sedation where this is in the patient's best interests. Expert advice should be sought where there is any doubt before commencing what could be a major procedure.
Patient involvement: For patients who have not previously used Entonox, explain what the gas is for and what is required of them. Give them an opportunity to practice a few breaths to check their technique prior to commencing the procedure. Time spent at this stage will ensure the patient is relaxed and gains full benefit from the system. Select a mask or mouthpiece that is appropriate for the patient and instruct him/her on how to hold the mask over the nose and mouth, or in the case of the mouthpiece, between the teeth sealing around it with the lips, and to then breathe normally.
Documentation: Documentation should confirm that proper patient instruction took place, and record the time period in which the gas was used. Generally, record keeping should also document an assessment of the pain experienced during and after the procedure and what steps have been taken to provide on- going comfort. Practical considerations: Check the amount of gas in the cylinder prior to commencing therapy, as it is important not to run out part way through a painful procedure. Check that the cylinder valve is turned on fully (at least two full turns) and use the demand valve test-button to demonstrate to the patient that the gas is flowing and familiarise him/her with the noise made on inspiration.
Procedure for administration: Encourage the patient to breathe the gas for around two minutes before commencing the procedure. Never hold the mask on the patient's face, as his/her active involvement is crucial to the safety of the Entonox system. Continually assess the patient's progress during the procedure. At all times the patient should be able to obey commands, but if a momentary loss of consciousness does occur, the seal around the mask or mouthpiece will be lost as it falls away and the demand valve will fail to operate causing the flow of gas to stop. On breathing normal air these effects will quickly wear off, at which point the patient may choose to continue using the gas. During dressing changes or debridement, the amount of pain will vary throughout the procedure. Sometimes painful events happen intermittently throughout the procedure and the patient must be given adequate warning to top-up as required in advance.
If only one person is involved in treatment, it is important to be especially vigilant and maintain frequent verbal contact.
Elderly patients may require a higher level of support and can experience difficulties maintaining a seal where dentures have been removed.
If an assistant is helping they should support and supervise the patient, but it is the responsibility of the treating officer to ensure that the assistant is aware not to hold the mask onto the patient's face.
Patients using Entonox for the first time will require observation after treatment until they have fully regained their normal level of alertness and balance.
Entonox gas is an established and safe short-term analgesic. It is ideal for patients undergoing wound dressing procedures where an element of both analgesia and distraction may be of benefit. Its historic use by midwives and paramedics and use in investigative procedures does not preclude its adoption by wound care nurses. There need be no great mystique about Entonox but it must be introduced alongside clear organisational/departmental policies regarding its use and training requirements of staff.
Indications: Pain from any source provided no contraindications are present.
Head injury with impaired consciousness
Heavily sedated patients (overdose)
Nitrogen narcosis (bends)
Severe facial injuries
Inability to follow the instruction (too young, senile, injury to both hands, mental handicap)
Precautions: Should be keep at temperature above - 6C. Temperatures below - 6C the gas separates. Store in a horizontal position when administering.
PENTHRANE (Inhaled Methoxyflurane)
Methoxyflurane is a volatile anaesthetic agent with significant analgesic properties at low sub-anaesthetic concentrations. The analgesic Methoxyflurane is a vaporous agent with mild anaesthetic properties. Like Entonox, this is a Schedule 4 Drug and is restricted to prescription use only.
Methoxyflurane is inhaled via the custom-designed Penthrane Inhaler.
Penthrane is supplied in 3ml bottles and is administered/delivered through a disposable plastic inhaler or ‘whistle, that may be connected to oxygen supply.
This method of delivery makes the drug more versatile in the pre-hospital environment and is ideal for first aid officers or medics who are not authorised to administer or do not have access to other pain relief agents such as morphine.
Each casualty should only be administered one and you should report the use of this drug to the ambulance officer. Be careful in confined space as the gas can be directed at you. The vaporous odour is sweet smelling and is often described as similar to ‘Juicy Fruit’ chewing gum. The analgesic effects can last for up to ½ hour after administration.
When using the Penthrane Inhaler, pour the contents of the 3ml bottle slowly into the base of the inhaler, making sure the inhaler is rotated so as to achieve an even distribution of the fluid onto the absorbent wick located inside the inhaler.
Access and storage : It must be securely stored where ever it is located (vehicle, first aid facility etc.).
Handling: A person must not carry, handle or store a restricted drug in a way that may allow the drug to mix with, or contaminate, food, drink or a condiment or a drug or poison for human or animal use even if the container in which the drug is carried, handled or stored breaks or leaks.
Each empty bottle must be returned along with a report to the Company Medical Officer after its use.
The Penthrox TM Inhaler is a tubular light-weight disposable polyethylene device containing a:
Polypropylene pad (to act as a wick, absorbing the Methoxyflurane)
One-way valve (to prevent blow-back into wick)
Dilutor hole (to vary the concentration of inspired Methoxyflurane)
22mm mouthpiece can be fitted to all ISO international standard mask
Key Usage Features:
Can be connected to oxygen supply
Wrist strap for support
Dilutor hole allows two inspired methoxyflurane concentrations
Disposable – single use (prevents cross infection)
Accepts standard ISO face mask
Features of Penthrane (Inhaled Methoxyflurane):
Potent analgesic effect in low concentrations
Pain relief commences after 3-4 breaths
Pain relief continues for 3-4 minutes after use
o Important when extricating trapped victim
Two inspired methoxyflurane concentrations:
o Diluter hole open: 0.2%
o Diluter hole closed: 0.4%
Duration of action in Penthrane Inhaler:
o 3mL: analgesia for up to 25 minutes
o 6mL: analgesia for up to 50 minutes
o May be extended by use of a simple plastic storage bag for the inhaler intermittently
Dosage limits: maximum 6mL/day and 15mL/week
Advantages of Penthrane
Penthrane has a number of advantages for emergency pain relief situations. They include:
1. Potent analgesic (pain relief) properties
2. Easy to train and simple to use
3. Inhaled (no need for injections)
4. Small, light and portable (easily given to inaccessible patients)
5. Disposable – single patient use only (prevents cross infection)
6. Easy to administer, handle and manage
7. Safe – no adverse reactions
8. No unsafe pollution in enclosed environments
9. Can be simultaneously administered with oxygen therapy
PHARMACOLOGY – PENTHRANE
Description : Central nervous system depressant with anaesthetic and analgesic qualities
Effects: Central nervous system depressant
Onset : 2 - 3 min
Duration: 3 - 5 min
Use: Pain management
Excessive doses may produce renal damage
A patient who has been administered Methoxyflurane for pain relief must go to
Hypersensitivity to Methoxyflurane
Patients under 1 year old
hospital by ambulance.
History of significant liver or renal disease
Untreated renal failure
Pre-eclampsia or eclampsia
Decreased LOC - head injury or drug induced
Acutely psychotic patients
Concurrent tetracycline use (eg doxycycline)
Preparation : 3ml sealed amber bottles. Contents of methoxyflurane are poured onto base of inhaler and absorbed by the internal wick.
Adult: Maximum dose - 6mls per day (Do not put any more than 3 mls in inhaler at any time as this increases risk of droplet inhalation). 15mls per week.
NOTE: 3 mls will remain active in the inhaler for about 30 minutes.
Paediatric Dose: As for Adult – Single dose only. Not to be given to children under 1 year of age.