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Pain is the most common emergency complaint. The World Health Organization supports optimal pain treatment as a fundamental human right (http://who.int/mediacetre/news/notes/2007/np31/en/). Several prehospital studies have shown inadequate analgesia for these patients. Factors associated with failures in the management of prehospital pain include underestimation of pain, underdosing of analgesia medications, underfrequency of dosing, and inappropriate withholding of analgesia. The importance of prehospital analgesia has been outlined by the Emergency Medical Services Outcomes Project in (the United States as follows: “the relief of discomfort might be the most important task EMS providers perform for the majority of their patients.” This sentiment was also advocated by the National Association of EMS Physicians (NAEMSP), who issued a position paper stating that the relief of pain should be a priority for every EMS system. A more to the point assessment of prehospital undertreatment of pain was given in a Basket editorial: “The blame for ‘oligoanalgesias’ must be laid at the door of physicians in authority who have, through ignorance, underplayed the physiologic and psychological benefits of analgesia and overplayed the potential deleterious side effects of agents that are commonly available.”

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OBJECTIVES

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  • Describe the goals of prehospital analgesia and sedation.

  • Discuss barriers to the administration of prehospital analgesia.

  • Describe pain assessment and prehospital pain scales.

  • Describe available pharmacological interventions.

  • Describe available local and regional anesthesia.

  • Discuss nonpharmacological interventions and therapies.

  • Describe the development of analgesia and sedation protocols.

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INTRODUCTION

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Pain complaints present unique challenges to EMS providers. These patients may be difficult, distraught, evasive, and seemingly unreasonable. A full understanding of the differing types of pain, their presentations, and a concise, systematic approach to the treatment of these patients is paramount to optimizing their care. Furthermore, it is important to note that there are advanced life support agencies functioning without access to controlled substances for their patients. It is therefore important for EMS medical directors to understand the importance of these concepts. It is the responsibility of EMS physicians and medical directors to ensure that the problem of oligoanalgesia is addressed in CQI and education programs.

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DEFINITION OF PAIN

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Pain is the most common reason for patients to seek medical attention in the United States. 1 The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and/or emotional experience associated with actual or potential tissue damage. It usually motivates the patient to withdraw from the offending stimulus.” 2 Pain is not only a sensory process, but also an affective, subjective phenomenon influenced by physiological processes and by diverse psychological and emotional processes. Most pain will resolve quickly once the stimulus is withdrawn. However, pain may at times persist despite stimulus removal and apparent healing. At other times, pain may develop in the absence of any detectable stimulus or damage.

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TYPES OF PAIN

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There are two categories of pain: ...

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