Pain Relief

Pain Relief (CPG A0501)

Notes - Quality analgesia

Consider dose reductions or longer dose intervals in small, frail or elderly patients
ALS Paramedics should consult for IV ketamine and / or further doses of opioids in any circumstance
where the maximum doses have been reached but the patient remains in pain.
Multi-modal analgesia is the preferred approach (e.g. paracetamol, opioid and methoxyflurane vs morphine alone).

Action - Moderate pain

IV Opioids + Paracetamol is the preferred approach if IV access is available / required.
- The IV route is preferred in frail or elderly patients.
IN Fentanyl or IN Ketamine + Paracetamol is the preferred approach if:
- IV access is NOT available / required
- IV access is delayed or unsuccessful
- Consider IN Ketamine if the first line approach with opioids has shown limited or no effect (e.g.
  minimal reduction in pain following 10 mg IV morphine or 100 mcg IV fentanyl).
IM Morphine:
- IN fentanyl / IN ketamine is contraindicated / has limited effect AND IV access is not available.
Methoxyflurane:
- Preferred agent for procedural pain or pain related to movement
- May also be used as a third line agent if required
- Should be used with other analgesics to optimise pain management

Action - Severe pain

Opioids + Ketamine is the preferred approach to managing severe pain.
There is no requirement that large doses of opioids be given prior to using ketamine. Initial
management may include both medications. A short period of time (e.g. 3 – 5 minutes) should ideally
be left between the two medications to gauge the patient’s response.
IV Ketamine:
- Advanced paramedics may use IV ketamine in preference to IN ketamine if IV access is
  immediately available
- ALS paramedics should consult for IV ketamine where initial IN ketamine analgesic
  management is inadequate.
IN Fentanyl and / or IN Ketamine and / or Methoxyflurane should be administered if IV access is
delayed or not available.

Managing side effects

Significant respiratory depression due to opioids:
- Titrate small doses of IV Naloxone as per CPG A0707 Overdose – other opioid overdose.
- Avoid complete reversal and the return of pain.
Hypersalivation is a known side effect of ketamine:
- Suction: On most occasions suctioning will be sufficient
- Atropine 600 mcg IV/IM (AP only) where hypersalivation becomes difficult to manage or the
  airway is compromised
Emergence reactions:
- Hallucinations or other behavioural disturbance associated with ketamine are less common in
  low doses as used for pain management.
- These reactions are transient and can be minimised by administering IV doses slowly (e.g. over
  1 – 2 minutes) and by reassuring the patient. This is particularly relevant for frail or elderly
  patients.
- Patients with poorly controlled psychiatric conditions involving psychosis such as
  schizophrenia may find some of the adverse effects of ketamine particularly distressing.
  Consider this risk against the potential benefit when planning analgesic approach.
- Midazolam 0.5 - 1 mg IV (ALS – consult only) - consider for significant or persistent reactions

Advanced Paramedic

Ketamine infusion preparation:
- Ketamine 50 mg up to 50 mL with Normal Saline to make 1 mg/mL dilution.
- Recommended infusion rate: 0.1 – 0.3 mg/kg/hr

Flow Chart

Dose table