Page 343 Acute Pain Management

reported that 51% of elderly patients with a fractured neck of femur were given prehospital
analgesia — methoxyflurane in 47% of cases, N 2O in 10%, and 6% received morphine
(Vassiliadis et al, 2002 Level IV). Similarly, in a 2005 survey from Australia, 55% of patients in
pain received analgesia by paramedics (Lord et al, 2009 Level IV).
Prehospital use of opioids may be increasing; in two surveys of 2005, 29% of patients with
isolated extremity injuries (Michael et al, 2007 Level IV) and 13% of females and 17% of males
in pain (Lord et al, 2009 Level IV) had been given morphine.
Paediatric patients may also not receive prehospital pain relief. One study of children with
fractures or soft tissue injuries reported that 37% received prehospital analgesic drugs (Rogovik
& Goldman, 2007 Level IV). Another, which included patients with a diagnosis of limb fracture
or burns, reported that analgesia was given to 51% of children between the ages of 5 and
15 years, but not to any child aged less that 5 years; a greater proportion of this younger
group (70% vs 54%) were given opioid analgesia once in the emergency department (Watkins,
2006 Level IV).
Despite such studies showing that pain relief prior to arrival in an emergency department
needs to be improved, and although pain relief has been acknowledged as a key area for
investigation, evidence regarding management of acute pain in patients in the prehospital
setting remains limited with few randomised controlled studies available. Although many
analgesic techniques that work in hospital environments have been transcribed to the
prehospital environment, these do not always comply with the ideal of simplicity, safety and
effectiveness when used in the field.
9.10.1 Assessment of pain in the prehospital environment

As in other settings, pain intensity is best assessed using patient self‐report measures such as
VASs (Galinski et al, 2005; Kober et al, 2002), VNRSs (McLean et al, 2004; Woollard et al, 2004; Rickard
et al, 2007; Bounes et al, 2008), VDSs (McLean et al, 2004; Vergnion et al, 2001), faces pain scales
(Rogovik & Goldman, 2007) (see Section 2). A ruler incorporating both visual analogue and faces
pain scales (Lord & Parsell, 2003 Level IV) has also been used to measure pain in patients prior to
arrival at hospital.
However, in some instances it may not be possible to obtain reliable self‐reports of pain
(eg patients with impaired consciousness or cognitive impairment, young children (see Section
10.3), elderly patients (see Section 11.2.3), or where there are failures of communication due
to language difficulties, inability to understand the measures, unwillingness to cooperate or CHAPTER 9
severe anxiety). In these circumstances other methods of pain assessment will be needed.

9.10.2 Systemic analgesics

The ideal prehospital analgesic agent should be simple to use, safe (both in terms of side
effects and adverse effects on the patient’s condition), effective, not lead to delays in
transport and have a rapid onset and short duration of action (Alonso‐Serra & Wesley, 2003)
so that it can be repeated as often as necessary and titrated to effect for each patient.
Consideration should be given to both choice of analgesic drug and route of administration.
Opioids and tramadol
The administration of systemic opioids as an effective prehospital analgesic is widespread.
Their application is influenced by not only the knowledge and judgment required to use them,
but also by the different drugs of dependence legislation found in most countries. In this
setting, use of IV or IN routes will enable a more rapid and predictable onset of action than
other routes of administration. Occasionally morphine is given intramuscularly in the

Acute pain management: scientific evidence 295