Pain Management

updated 11th November 2017

 

Pain in itself is not life threatening but pain can cause physiological changes in blood pressure, breathing and pulse.  This is interesting but the main reason to manage a casualty’s pain, is to make your life and theirs more bearable.

A pain-free casualty will be

  • more compliant

  • more willing to engage in their own treatment

  • less dependent on others

  • easier to move and transport

  • more willing to accept potentially painful procedures such as examination or wound cleaning, for example.

  • Better rested with less disturbed sleep, less stressed and generally a nicer person to be around. This is especially important in remote areas when living in small groups or teams and in confined areas!

 

What is Pain?

Pain has two primary etiologies: nociceptive and neuropathic.  The difference is whether the pain stimulus comes from a nerve receptor, intended to sense pain, touch, temperature, or pressure (nociceptive); or if the pain stimulus comes directly from injury to the nerve itself (neuropathic).

Nociceptive pain, for example, is the pain that occurs when you hit your thumb with a hammer. The impact stimulates the nerve receptors, sending pain signals to the brain. If you push on the area of pain, it will make the pain worse. 

Neuropathic pain, on the other hand, is radiating or referring pain that occurs when a nerve itself is injured. For example, the casualty may have ruptured a disk in their lower back, and that disk is now compressing the left L5 nerve root of the sciatic nerve.  As a result, they will have pain that radiates down the back of their leg to their foot.  When you push on the areas of apparent pain – the foot - it does not cause more discomfort because the problem is at the disc, not where the pain is presenting.

Nociceptive pain is easily managed with non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen in the US) and opioids.  Neuropathic pain does not respond as well to these usual pain relievers, making it harder to manage.

There are two methods we can employ to help reduce pain; medicated and non-medicated.

 

Non-Medicated Pain Control

Pain can be reduced, to some degree, without the need of medications. 

Rest: Rest for the first 48-72 hours (1)

Ice: Apply cool compresses to the affected area to cause vasoconstriction, reducing swelling and thus reducing pain.  This also minimizes any further bleeding into the damaged tissue.  Ice is a metaphor for cool – NEVER apply ice directly to skin.  If you have ice available (from a drinks bucket, a bag of frozen peas or even snow or ice itself), wrap the ice in something wet which will conduct heat quickly but will reduce the chance tissue damage.

A regime of a 15-20 minutes every 2-3 hours during the day for the first 48-72 hours following the injury (1).  This ensures vasoconstriction does not lead to frostbite in the affected limb and, furthermore, alternate cooling and rewarming is more effective than continual cooling as the affected area also needs a good supply of blood to remove waste products and promote healing.

Comfortable position:  The conscious casualty will always support an injury in a comfortable position.  Again, telling casualties to elevate an injury if it is not already elevated is a nonsense.   The comfortable position will provide more pain relief than the purported benefits of elevation.  Don’t worry about whether you should be applying a ‘high arm sling’ or a ‘broad arm sling’ – the best treatment you can provide to the casualty here is to support the injury in the position found.

In terms of positioning the casualty, conscious casualties will always adopt a comfortable position, be it laying down, going 'foetal' or sitting up.   Do not force a casualty into a position; let them adopt the position they want.

Further reading - Casualty Positions

Reassurance – Pain is a physiological response to either the stimulus of nerve receptors or the presence of chemical mediators but the perception of pain can be exacerbated or suppressed depending on the level of emotional support provided to the casualty.  Do not underestimate the value of emotional support.

Distraction – By the same token, do not do everything for the casualty.  The best way to make someone feel helpless is to treat them as though they are.  Engaging the casualty in their own treatment and keeping them occupied is an effective method of distraction.

Traction can relieve pain but training is essential.

 

Medicated Pain Control

There are a lot of myths which are still spread in society and on some formal training courses regarding our ability to give casualties medication.   Providing over-the-counter pain relief to casualties is appropriate if done properly.  This article provides simple advice on over-the-counter medicines, this article goes into more detail on the administering of medicines.

 

Aspirin

A mild analgesia that is known for its additional quality of ‘thinning the blood’.  It doesn’t actually thin the blood but it is what’s known as a platelet aggregation inhibitor; it inhibits blood clotting.  This can be used to good effect as prophylactic medication at altitude or for these with cardiac problems but can cause continued bleeding in a soft tissue injury.

300mg – 600mg every 6 hours to a maximum of 4g a day.  Take with food and avoid if there is a history of stomach ulcers or an allergy to ibuprofen.

Paracetamol

A much underrated pain relief; paracetamol is an effective pain killer to the extent that IV paracetamol is regularly used in A&E departments where lay-people would commonly expect much ‘stronger’ pain relief to be used.

Paracetamol – like all drugs – does not come without warning.  Paracetamol is toxic in comparatively small amounts. Current guidance for adults (over 50kg) is 500mg – 1g (one to two tablets) every 4-6 hours to a maximum of 4g a day (or 6hrs for those with renal impairment (2).

A case for a loading dose of 2g followed by up to two further doses of 1g every 4-6 hours has been made with demonstrated lower pain scores and greater duration of effective pain relief with no increase in side-effects or markers of toxicity (2).

Ibuprofen

Ibuprofen (or ‘brufen’) is well known as an anti-inflammatory and therefore ideal for bone or joint injuries however as platelet aggregation inhibitor (although to a lesser degree than aspirin) it should be avoided in the first two days of injury as it may promote bleeding into the tissue (3-5) , in which case start with paracetamol and add ibuprofen if needed.

200mg-400mg 8 hourly – with food – to a maximum of 1200mg a day.

Paracetamol + Ibuprofen

Paracetamol and Ibuprofen can be combined safely to increase the efficacy to greater effect than some opiates (6-9).  

400mg ibuprofen 8 hourly (to a maximum of 1200mg in 24hrs) + 1g paracetamol 6 hourly (to a maximum of 4mg in 24 hours)

Codeine

Both ibuprofen and paracetamol are currently available with codeine over-the-counter.  These represent the strongest openly available analgesics.

Codeine has a constipative effect so your casualty may need to consider laxatives after several doses of codeine.  Codeine is addictive and should not be taken for more than three days.

 

Further Reading - The Medicine Cabinet

References

  1. National institute for Clinical and Healthcare Excellence (2016). "Sprains and strains". Clinical knowledge Summaries. http://cks.nice.org.uk/sprains-and-strains#!scenario Accessed 28th July 2016

  2. Sharma VC, Mehta V. (2014) “Paracetamol: mechanisms and updates”. Continuing Education in Anaesthesia Critical Care & Pain. Volume 14, Issue 4, August, Pages 153–158.

  3. Braund, R., Haxby Abbot and J. ( 2007 ) Analgesic recommendations when treating musculoskeletal sprains and strains. New Zealand Journal of Physiotherapy. 35( 2), 54- 60.

  4. Orchard, J.W., Best, et al ( 2008 ) The early management of muscle strains in the elite athlete: best practice in a world with a limited evidence basis. British Journal of Sports Medicine. 42( 3), 158- 159.

  5. Carter, D. and Amblum-Almer and J. ( 2015 ) Analgesia for people with acute ankle sprain. Emergency Nurse. 23( 1), 24- 31

  6. Beaudoin FL. (2018) “Combination of ibuprofen and acetaminophen is no different than low-dose opioid analgesic preparations in relieving short-term acute extremity pain”. BMJ Evidence-Based Medicine. 23. 197-198.

  7. Kelly LE, Sommer DD, Ramakrishna J, Hoffbauer S, Arbab-Tafti S, Reid D, Maclean J, Koren G. (2015) “Morphine or Ibuprofen for post-tonsillectomy analgesia: a randomized trial”. Pediatrics. 135(2):307-13.

  8. Mehlisch DR, Aspley S, Daniels SE, Southerden KA, Christensen KS. (2010) "A single-tablet fixed-dose combination of racemic ibuprofen/paracetamol in the management of moderate to severe postoperative dental pain in adult and adolescent patients: a multicenter, two-stage, randomized, double-blind, parallel-group, placebo-controlled, factorial study.". Clinical Therapeutics. Jun 32 (6): 1033-4

  9. Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. (2017) "Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department - A Randomized Clinical Trial". Journal of the American Medical Association. 318(17):1661–1667.