synthesis
of art and science is lived by the nurse in the nursing act Art & science | | The
acute
care
analgesia
JOSEPHINE G PATERSON
MANAGEMENT OF PAIN IN
PRE-HOSPITAL SETTINGS
Michael Parker and Antony Rodgers discuss ways to
measure pain in trauma patients and ask why some
practitioners provide patients with inadequate pain relief
Correspondence
[email protected]
Michael Parker is a lecturer in
acute and critical care nursing
at the University of York
Antony Rodgers is a paramedic
at the Yorkshire Ambulance
Service NHS Trust
Date of submission
April 1 2015
Date of acceptance
May 19 2015
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
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en-author-guidelines
Abstract
Assessment and management of pain in pre-hospital
care settings are important aspects of paramedic
and clinical team roles. As emergency department
waiting times and delays in paramedic-to-nurse
handover increase, it becomes more and more vital
that patients receive adequate pre-hospital pain
relief. However, administration of analgesia can be
inadequate and can result in patients experiencing
oligoanalgesia, or under-treated pain. This article
examines these issues along with the aetiology of
trauma and the related socioeconomic background of
traumatic injury. It reviews validated pain-assessment
tools, outlines physiological responses to traumatic
pain and discusses some of the misconceptions
about the provision of effective analgesia in
pre-hospital settings.
Keywords
Analgesia, oligoanalgesia, pain assessment,
pain management, injury, trauma
IN THE UK, major trauma is the leading cause of
death in people aged between one and 40 years
(National Confidential Enquiry into Patient Outcome
and Death 2007). Of about 20,000 major trauma
incidents that occurred in 2007, 5,400 resulted in
death and about 10,000 resulted in life-changing
disabilities (National Audit Office (NAO) 2010).
Incidence of traumatic injury is closely
related to sociodemographic background and
gender. Traumatic injury is more likely to occur
in lower socioeconomic groups, for example,
16 June 2015 | Volume 23 | Number 3
and three quarters of trauma patients are males
aged between 16 and 20 years (NAO 2010). According
to the charity Brake (2014), drivers aged between
17 and 24 years represent only 1.5% of UK driving
licence holders, but are likely to be involved in
12% of fatal or near-fatal motor vehicle collisions
or accidents. Brake (2014) cites inexperience and
over confidence as the main factors causing such
accidents, and suggests that the two factors correlate
with a reduced ability to identify hazards and
a willingness to engage in risk-taking behaviour,
such as driving under the influence of alcohol or
drugs. The latter finding is also emphasised by
Bonar et al (2015).
Emotional responses to traumatic events include
extreme fear, hallucinations and helplessness
(Bronson 2000). These responses are innate
and initiated whenever there is a threat to
life or loss of control, and can have profound
psychological effects.
The effects of trauma on patients and their
families is too big to quantify (Bronson 2000),
and survivors of trauma are often reluctant to talk
about their experiences (Geisser et al 1996). Anyone
involved in stressful, life-threatening or catastrophic
events can experience post-traumatic stress disorder
(PTSD), although the symptoms may not become
apparent for days, weeks or even months (National
Institute for Health and Care Excellence (NICE) 2005).
The development of PTSD is closely linked to
maladaptive mechanisms for coping with trauma
and pain, whereby untreated pain can produce
psychological stress and anxiety, as well as
neurohumoral changes, neuronal remodelling,
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EMERGENCY NURSE
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Pain management
Pain is a complex experience that is unique to
each person who feels it. How pain is felt depends
partly on the age, gender, ethnicity and prior
experiences of the individual who feels it, and so
can be difficult to measure objectively (Joint Royal
Colleges Ambulance Liaison Committee (JRCALC)
2013). Nevertheless, a number of pain measurement
tools have been developed to aid the assessment of
pain, and the effectiveness of pharmacological and
non-pharmacological interventions to manage it
(Curtis and Morrell 2006).
Physiology Acute pain is usually associated with
injury, and serves as a warning of actual or potential
tissue damage. Pain receptors are made up of bare
sensory nerve endings, which weave through all
types of body cell other than those in the brain.
The activation of these nociceptors initiates an
action potential, which is transmitted via the axons
of afferent, or sensory, nerves. Afferent pathways
synapse in the dorsal horn of the spinal cord.
Pain signals are then conveyed to the cerebral cortex
via higher order neurones and the spinothalamic tract.
The signal is then perceived and modulated (Martini
and Bartholomew 2010, Waugh and Grant 2010)
The peripheral nerve pathways comprise
two types of nociceptor fibre: myelinated A-fibres
and unmyelinated C-fibres (Waugh and Grant 2010).
Myelinated A-fibres are sensitive to mechanical and
thermal stimuli, and can convey signals rapidly.
Their signals are perceived as localised sharp pain.
Unmyelinated C-fibres respond to mechanical,
thermal and chemical stimuli, but conduct signals
slowly. Their signals are perceived as poorly
localised, dull and aching pain.
Mechanical, thermal or chemical damage
releases chemicals such as leukotrienes,
bradykinins, serotonin, histamine and thromboxane,
which activate nociceptors. Although prostaglandins
are also associated with pain, they do not stimulate
receptors directly. Instead, they cause small blood
vessels in the damaged areas to dilate so that more
blood is able to flow into the regions surrounding
them. This causes redness and swelling, which leads
to oedema. The swelling and oedema cause pressure
on the nerve endings, which results in pain (Waugh
and Grant 2010).
Nociceptors are found in the skin, periosteum,
arterial walls, teeth, joint surfaces and in the falx
and tentorium of the cranial vault. They propagate
impulses to their cell bodies in the dorsal horn of
the spinal cord, where a neurotransmitter known
as ‘substance P’ is released. Substance P then relays
the signals through higher order neurones and the
spinothalamic tract to the cortex (Dawson 2009,
Martini and Bartholomew 2010).
Pain scales The Wong-Baker Face system (Wong
et al 2001) is used in many emergency care settings
for the assessment of pain in children or patients
who cannot communicate easily (Krigger 2006).
The system comprises a numerical scale of between
zero and six, where zero represents no pain and
six represents the worst pain. Each degree of pain
is illustrated by the drawing of a face with an
expression ranging from distressed to happy.
Another assessment tool that is used primarily
with children is the Face, Legs, Activity, Crying,
Consolability (FLACC) scale (Merkel et al 1997).
This comprises a shorter numerical scale in which
zero represents no pain, one represents moderate
pain and two represents severe pain. Clinicians
are expected to make subjective assessments of
children’s pain based on the degree of discomfort or
pain shown in their faces, legs, activities, how much
they are crying and how easily they can be consoled.
The Wong-Baker Face system and FLACC scale
may seem basic, but they are useful in pre-hospital
settings, especially with people who have
communication difficulties or where no alternative is
available (Kenyon 2009).
Alternative pain-measuring tools include the Visual
Analogue Scale (VAS) (Crichton 2001), a 100mm line
on which patients mark the degree of pain they are
experiencing between no pain at one end of the scale
and severe pain at the other. Illustrations similar to
those in the Wong-Baker Face system can be added
to the scale to help to communicate its purpose to
patients who have difficulty understanding what is
asked of them. As Crichton (2001) acknowledges,
the VAS is a subjective method of assessment, but it
can be useful in assessing pain in older patients and
those with difficulties understanding.
The Numerical Rating Scale (NRS) (Downie et al
1978) is an 11-point numerical rating scale in which
zero represents no pain and ten severe pain, and on
which patients attribute a numerical value to the
level of pain they experience. Some patients struggle
with the concept of applying a subjective value to
pain, however.
and long-lasting psychological and emotional
distress (Dunwoody et al 2008).
Emergency care practitioners should not
underestimate the effects of psychological trauma
on the individuals concerned and their families
(NICE 2005). Central to the management of such
patients is pain control (Iqbal et al 2012), and pain
management should be regarded as a crucial element
of effective pre-hospital care.
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In a comparison of the VAS and NRS, Williamson
and Hoggart (2005) conclude that both are
appropriate, valid and effective for assessing pain.
However, they also note that interpreting pain
scores on a small vertical line requires dexterity,
and conclude that the NRS is more effective and
simpler to use than the VAS.
In an examination of the relationship between
NRS scores and the administration of analgesia
to 150 patient participants, Silka et al (2004)
found that 60% of the participants assessed
with the NRS, but only 30% assessed with the
VAS, received adequate and effective pain relief.
The researchers conclude that the NRS is the most
appropriate in pre-hospital care environments
because it allows rapid and accurate re-assessment
of pain, thus allowing clinicians to titrate analgesia
appropriately (Williamson and Hoggart 2005).
Meanwhile, Bijur et al (2006) found that,
when recording pain scores every 30 minutes to
show pain progression over a two-hour period,
the NRS is more accurate and easier to use than
the VAS in emergency departments (EDs). Of the
108 patients in their study, regular pain scores were
documented in 103.
The Verbal Rating Scale (VRS) (Berthier et al 1998)
is a five-point scoring system where one represents
no pain and five represents severe pain. In comparing
the effectiveness of the NRS, VAS and VRS when
used with 200 trauma patients and 90 non-trauma
patients, Berthier et al (1998) found a correlation
in pain scores between the NRS and VAS.
The effectiveness of the VAS and VRS were limited,
however, due to a lack of understanding among the
patients. Almost 20% of patients did not understand
how to use the VAS and 11% did not understand the
how to use the VRS, but 96% of patients understood
the NRS. Berthier et al (1998) conclude, therefore,
that the NRS is the most appropriate measurement of
pain in emergency care settings.
Although most pain-assessment studies are
carried out in acute hospital environments,
their findings are relevant and transferable to
pre-hospital settings. With the advent of paramedic
practitioners, hazardous area response teams and
helicopter emergency medical services there is scope
for research into pre-hospital pain management.
Until this research is undertaken, emergency nurses
should be aware of what pain-assessment tools are
available and should choose the most appropriate
tool for individual patients during specific events.
Pain control Research into effective pain control in
pre-hospital settings is limited and most studies of
acute pain relief focus on EDs. Pain assessment and
EMERGENCY NURSE
management are important issues in pre-hospital
care environments, yet are not always carried out
(Curtis and Morrell 2006). For example, Abbuhl
and Reed (2003) conducted a retrospective review
over 18 months of patients with isolated, painful
extremity injuries who had been transported by
emergency ambulance to EDs. Exclusion criteria were
inter-hospital transfers, and patients with altered
levels of consciousness, haemodynamic instability,
head or multiple injuries, intoxication or organic
mental health problems. The researchers found that,
of 706 patients studied, only 104 were not excluded
by these criteria and, of these, only 13 received
analgesia, which suggests that pre-hospital pain
assessment and management can be mismanaged.
They conclude that assessment and treatment of
pain should be a priority in pre-hospital settings,
and that effective pain management can result in
positive patient outcomes, including a reduction in
anxiety and fewer adverse physiological responses
(Abbuhl and Reed 2003).
In an examination of the pre-hospital assessment
and management of pain by 155 paramedics,
Hennes et al (2005) conclude that awareness of
analgesia protocols is vital to pain management,
and that the main reason that administration of
analgesia by paramedics is inadequate is that they
experience difficulties when assessing pain and the
perception of pain.
Under-treatment The term ‘oligoanalgesia’ describes inadequate
treatment of acute or chronic pain. The reasons
for oligoanalgesia are complex, but include
preoccupation with diagnosis and treatment
of underlying medical conditions, attending
to traumatic injuries, concern about masking
symptoms, concern about causing addiction to
analgesics, ineffective communication and language
barriers (Curtis and Morrell 2006).
These findings are supported by Walsh
et al (2013), who conducted a US-based qualitative
research study in which they interviewed
15 paramedics with more than one year’s experience.
The paramedics were employed by five emergency
medical service agencies made up of private and
hospital-based providers in urban and rural settings,
and were asked to reflect on their experiences of
delivering pain relief in pre-hospital environments.
Results show that the paramedics were reluctant to
administer pain relief without seeing either physical
or physiological evidence of pain, such as limb
deformities or changes in vital signs.
The withholding of analgesia when vital signs
are normal is based on the misconception that
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Art & science | acute
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analgesia
pain always initiates a physiological response,
an association that has never been validated. Lord and
Woollard (2011) published a retrospective study of
adults with Glasgow Coma Scale (GCS) scores greater
than 12 who had been assessed by paramedics
in a metropolitan area over a seven-day period in
2005. The 3,357 eligible patients then self-assessed
their pain using an NRS and 1,268 reported a pain
score greater than six. The researchers found no
meaningful correlation between pain scores and
changes in vital signs, and conclude that this finding
demonstrates that the severity of pain reported by
adult patients is not validated by their vital signs
(Lord and Woollard 2011).
The paramedics interviewed by Walsh et al (2013)
also disclosed an unwillingness to administer strong
doses of opioids, but preferred to opt for initial
loading doses of intravenous morphine sulphate
5mg. Their choice of dose was based on a suspicion
of potential drug-seeking behaviour in the patients
concerned and uncertainty about masking pain-related
symptoms. The study concludes that the paramedics’
attitude and lack of understanding prevented the
administration of appropriate pain relief.
Although no valid conclusions can be drawn
from Walsh et al (2013), under-treatment of pain in
pre-hospital environments is a recurring theme in
the literature. For example, McEachin et al (2002)
reviewed 124 patients with lower limb injuries
and possible hip fractures who had been
transported to EDs over a four-month period. Of the
124 patients, only 22 received pre-hospital analgesia,
while 113 received analgesia once they arrived at
the ED. Most of those who received pre-hospital
analgesia were young people with lower extremity
fractures. These findings demonstrate inadequate
pre-hospital pain assessment and management.
In a retrospective study, Albrecht et al (2012)
analysed patients transported to EDs by air
ambulance in Switzerland. Swiss air ambulance
teams consist of pre-hospital care physicians
and paramedics, and the review focused on their
decision-making skills. A total of 4,904 incidents
were analysed with 1,202 meeting the inclusion
criteria of patients being aged 16 years or over,
with GCS scores of 13 or greater and NRS scores of
three or more on arrival at the receiving hospitals.
Under-treatment of acute pain was indicated by
documented NSR scores of three or more on arrival
at the receiving hospitals, and no administration
of analgesia. Findings show that 43% of patients
were under-treated for pain by clinicians at the
scene. The most frequently injured body parts were
the limbs, in 66% of patients, and more than 50%
of patients had multiple injuries.
The researchers do not discuss non-pharmacological
interventions, such as splinting, which the JRCALC
(2013) advocates as an effective non-pharmalogical
analgesic technique that can prevent unnecessary
movement of limbs, and thus reduce anxiety about
associated anticipated pain. It should also be noted
that Albrecht et al (2012) do not mention the possible
exacerbation of pain or discomfort caused by spinal
immobilisation and associated spinal board discomfort
(Connor et al 2015, Parker 2015). These undocumented
non-pharmacological variables could be an important
consideration when assessing pain using the NRS on
arrival at hospital.
Green (2012) suggests that evidence of
oligoanalgesia is flawed due to its retrospective
nature, and argues that isolated pain scores do
not necessarily suggest that clinicians under-treat
patients’ pain. Green (2012) also says that a review
of a large database of medical documentation for
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EMERGENCY NURSE
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Management of acute pain is a fundamental part
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poor. The classic definition of pain as ‘whatever the
experiencing person says it is, existing whenever
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1968) appears to be discounted by some clinicians
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Conflict of interest
None declared
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