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Acupressure performed by during prehospital transport using ‘true points’ led to better pain
relief and less anxiety than acupressure using ‘sham points’ (Kober et al, 2002 Level II; Barker et
al, 2006 Level II; Lang et al, 2007 Level II) or no acupressure (Kober et al, 2002 Level II).
Local active warming resulted in significant analgesia for females in pelvic pain during
prehospital transport (Bertalanffy et al, 2006 Level II).
9.10.5 Analgesia in specific conditions

Acute cardiac pain
The mainstay of analgesia in acute coronary syndrome is the restoration of adequate
myocardial oxygenation, including the use of supplemental oxygen (Pollack & Braunwald, 2008;
Cannon, 2008) and nitroglycerine (Henrikson et al, 2003 Level IV). Opioid analgesia may also be
required (see Section 9.6.3).
Abdominal pain
As noted in Section 9.6, administration of opioid drugs does not interfere with the diagnostic
process in acute abdominal pain.
Patients with a head injury
Caution is often expressed about the use of opioids for pain relief in patients with a head
injury (Thomas & Shewakramani, 2008). This is largely because of the potential adverse effects of
opioids and their ability to interfere with recovery and neurological assessment, as well as the
concern that opioid‐induced respiratory depression will lead to hypercarbia and increased
intracranial pressure (Nemergut et al, 2007). While there is little specific information regarding
the use of opioids in patients with a head injury in the prehospital setting, they have been
safely used in patients after craniotomy (see Section 9.1.5).
The use of opioids in patients with a head injury in the prehospital environment will need to
be based on an individual risk‐benefit assessment for each patient.

Key messages
1. Intravenous morphine, fentanyl and tramadol are equally effective in the prehospital
CHAPTER 9 2. Nitrous oxide is an effective analgesic agent in prehospital situations (N) (Level IV).
setting (N) (Level II).

3. Methoxyflurane, in low concentrations, may be an effective analgesia in the hospital and
prehospital setting (N) (Level IV).
4. Ketamine provides effective analgesia in the prehospital setting (N) (Level IV).
5. Moderate to severe pain is common in both adult and paediatric patients in the
prehospital setting (N) (Level IV).

The following tick boxes  represent conclusions based on clinical experience and expert
opinion.
 The ideal prehospital analgesic agent should be simple to use, safe, effective, not lead to
delays in transport and have a rapid onset and short duration of action 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 (N).
 Non‐pharmacological measures are effective in providing pain relief and should always be
considered and used if practical (N).

298 Acute Pain Management: Scientific Evidence