Prehospital Pain Management: Evidence-Based Guidelines

This project aimed to establish evidence-based guidelines for the administration of analgesics by Emergency Medical Services (EMS) clinicians for moderate-to-severe pain. Here, a systematic review conducted by the University of Connecticut Evidence-Based Practice Center was used to gather evidence. A technical expert panel (TEP) consisting of subject matter experts was assembled to develop these guidelines. The panel formulated a series of PICO questions based on the key questions identified in the systematic review, including a specific question on analgesia in pediatric patients.

The following are the recommendations:

1. The recommendation strongly supports intranasal (IN) fentanyl use over intramuscular (IM) or intravenous (IV) opioids for treating moderate-to-severe pain in pediatric patients before IV access or without (or who do not have an indication for) IV access (strong recommendation, low certainty of evidence). Once IV access is established, a conditional recommendation for either IN fentanyl or IV opioids was stated (conditional recommendation, low certainty of evidence).

2. For initial pain management in the prehospital setting, IV acetaminophen (APAP) was recommended over IV opioids alone, if IV APAP is available, affordable, and easy to administer (conditional recommendation, low certainty of evidence). 

3. IV non-steroidal anti-inflammatory drugs (NSAIDs) or IV opioids can also be used (conditional recommendation, moderate certainty of evidence).

4. Furthermore, IV NSAIDs over IV APAP can also be used for initial pain management in the prehospital setting. When considering oral analgesics, PO NSAIDs or PO APAP should be preferred (conditional recommendation, low certainty of evidence).

5. Regarding the initial moderate-to-severe pain management in the prehospital setting, either IV ketamine or IV NSAIDs should be preferred (conditional recommendation, moderate certainty of evidence). 

6. Either IV ketamine or IV opioids should be preferred for the initial moderate-to-severe pain management in the prehospital setting (conditional recommendation, very low certainty of evidence).

7. If opioids are chosen for pain management, either IV morphine or IV fentanyl should be chosen for treating moderate-to-severe pain in the prehospital setting (conditional recommendation, low certainty of evidence).

8. A combination of weight-based IV opioids and weight-based IV ketamine over weight-based IV opioids alone is not recommended for initial pain management in the prehospital setting (conditional recommendation, very low certainty of evidence).

9. Comparison between the combination of IV opioids plus IV ketamine versus IV ketamine alone for initial pain management in the prehospital setting is not warranted – due to significant uncertainty and incomplete information (conditional recommendation, insufficient evidence).

10. The recommendations suggested against the comparison between nitrous oxide and IV opioids for initial pain management of moderate-to-severe pain in the prehospital setting.

Of note, the recommendations do not specify the specific cause of the pain in the evidence base. The evidence primarily focuses on traumatic pain, particularly limb fracture pain, while severe injuries, multi-trauma, burns, and non-traumatic pain like renal colic are not extensively represented in the evidence base.

Overall, the recommendations highlight the availability of various effective options, including non-opioid analgesics like NSAIDs, APAP, and ketamine, for managing moderate-to-severe pain in the prehospital setting. This emphasizes the importance of EMS medical directors and clinicians considering a range of medications when designing patient care guidelines and addressing acute pain. 

The availability of intranasal fentanyl for pediatric patients may address barriers to pain management in this population, such as difficulties in obtaining IV access, and enhance the number of children receiving appropriate analgesia while being accepted by patients and caregivers.

Source: Lindbeck G, Shah MI, Braithwaite S, et al. Prehosp Emerg Care. 2023;27(2):144-153. doi:10.1080/10903127.2021.2018073