Advanced Paramedic Practitioners
ADVANCED CLINICAL OPERATING PROCEDURES
TITLE
Analgesia
AUTHOR
Dr Neil Thomson, Assistant Medical Director East
PRINCIPLE
Dr Fionna Moore, Medical Director
REVIEWERS
Mark Whitbread, Director of Paramedic Education & Development
AUTHORISED BY Dr Fionna Moore, Medical Director
REVISION
Dr Fenella Wrigley
AUTHORISED BY Interim Deputy Medical Director
Advanced Paramedic Practitioners
APPLICATION
Consultant Paramedics
Named Paramedics
THIS
DOCUMENT
ACOP 004 v1.0
REPLACES
ISSUE DATE
15th May, 2015
REVIEW DATE
May 2016
REFERENCE
ACOP 004
VERSION
1.2
Smith, Scarth and Sasada: Drugs used in Anaesthesia and Critical Care,
FURTHER
4th Edition, 2011
READING
LAS PGD: Ketamine
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ACOP 4 – Analgesia
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Version Number
Revisions
1st April 2014 NT
0.1
Initial Draft
15th April 2014 NT
0.2
Minor amendments following comments from reviewers
25th April NT
0.3
Minor amendments following review with APP Group
29th April 2014, FPM, NT
1.0
Final Sign-off
1st May 2015
1.1
Fenella Wrigley, Neil Thomson, Ian Wilmer
15th May 2015
1.2
Final Release
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ACOP 4 – Analgesia
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INTRODUCTION
Pain relief is important for many clinical reasons, but most importantly, it is humanitarian. A fundamental
principle of prehospital care is that no patient should have his or her analgesic needs ignored.
LICENSING & RESTRICTIONS
Only paramedics who have been appropriately trained and who are authorised by the Medical
Director may work to these guidelines.
Autonomous use of a medicine not listed in the in the UK Ambulance Service Clinical Practice
Guidelines is restricted to paramedics who are authorised under an appropriate Patient Group
Direction.
ASSESSMENT
1. Identify the cause of the pain, and establish what makes it worse, and what makes it better
2. Assess the psychological and physical impact that it is having on the patient
3. Determine the priorities in the care, and consider where analgesia sits within these priorities. Bear
in mind that addressing pain can have a significant positive impact on abnormalities detected in a
primary survey. For example, titrated IV analgesia allows more effective breathing in a patient with
fractured ribs, and manipulation and traction of a fractured femur which minimises further blood
loss.
STRATEGY
1. Use a step-wise approach to analgesia, taking full advantage of non-pharmacological means such as
reassurance, distraction and splinting injured extremities.
2. Titrate analgesia to effect – whilst doses can be estimated on the patient’s weight, age and
physiology, the actual amount needed depends on the circumstances, the injury and the individual
patient.
3. It is not necessary to use every step on the pain ladder, or to use them in order: IV analgesia may
be needed to allow splinting.
4. Consider the risks of administering IV analgesia: small doses, well within the analgesic range, can
have significant side effects in the shocked patients.
5. Morphine is more effective and appropriate in abdominal and cardiac pain, and in penetrating
trauma
6. Ketamine is more effective for orthopaedic injuries and burns. It should not be used for cardiac or
abdominal pain, or chronic pain. Ketamine should not be used in palliative care.
PREPARATION
The APP is responsible for checking and confirming the position, patency and security of IV lines
that have been placed by other team-members.
The monitor must be in a position that can be seen at all times
The following equipment must be immediately available:
Bag-Valve-Mask-Reservoir (BVMR), including the appropriate sized mask
Suction (tested and functional) with a range of rigid and flexible catheters
Essential and advanced airway management equipment
Spare oxygen cylinder
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All drugs should be checked by two clinicians.
When cross checking ask the question “what is this?” which prompts the checker to stop and read the vial
or ampoule, rather than telling the checker what the drug is, which may elicit a positive or confirmatory
response without a proper check.
Drugs must only be drawn up in the stipulated concentrations and syringe sizes. This greatly reduces the
risk of error.
All syringes must be labelled with an approved colour-coded label, with the concentration clearly marked.
“TALK THROUGH”
1. Make sure that the crew have considered the indications and risk assessment
2. One clinician must have the sole responsibility for monitoring and maintaining the patient’s airway.
3. Make sure that this plan is communicated to all present, and that specific tasks have been allocated
and understood.
4. Make sure that everything is in place to splint or move the patient as soon as analgesia takes effect.
MEDICATIONS
KETAMINE
Presentation
Ketamine is available in a variety of strengths and presentations. The LAS will aim to only stock vials or
ampoules containing 10mg/ml of ketamine. It is recognised that at the time of writing this ACOP there is a
shortage of ketamine within the UK. As such it is possible that both the strength and presentation may have
to change.
Suggest we add in the bit about consideration for midazolam
Benefits
At low doses, ketamine is a potent analgesic agent, with a rapid onset of action. In higher doses it provides
a degree of dissociation. It is very effective in traumatic pain and burns.
It is a sympathomimetic – there is a lower risk of fall in cardiac output, and in appropriate doses, it
preserves airway reflexes and respiratory effort.
Disadvantages
At higher dose (sedative or anaesthetic, not analgesic) there is a small risk of hypersalivation (which can, if
needed, be managed with a standard dose of IV atropine – 500-600mcg in an adult, 20mcg/kg for children)
and a very rare risk of laryngospasm.
An emergence reaction is sometimes seen in patients recovering from a sedating dose. This is more
common when the patient is still being subjected to painful stimuli as the drug is wearing off, and can be
managed with small doses of IV midazolam, and / or further ketamine.
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Preparation
Ketamine as a 10mg/ml solution needs no preparation.
Higher concentration preparations should be diluted down to 10mg/ml as follows:
50mg/ml solution
In a 5ml syringe draw up 1ml of solution followed by 4ml of water for injection or normal saline,
making a total of 5ml of 10mg/ml solution
100mg/ml solution
In a 10ml syringe draw up 1ml of solution followed by 9ml or water for injection or normal saline,
making a total of 10ml of a 10mg/ml solution
Syringes must always be labelled with the correct colour coded label and strength. All syringes should be
capped.
Dose
Adults and children over 12 years:
Give a bolus of up to 10mg IV (or IO) (or 0.1mg/kg) followed by a 10-20ml flush. Four additional doses of up
to 10mg (i.e. a maximum of 50mg) may be given.
Allow sufficient time (at least two minutes) for the drug to work before increasing the dose, noting that
drugs take longer to circulate and take effect in patients with poor cardiac output. In all patients it may take
up to 15 minutes to notice the maximal cumulative effect of analgesia.
If higher doses are needed, advice must be sought from the on-call LAS clinician.
Children under 12 years
Up to 0.1 mg / kg, titrated to effect, either IV or IO, after discussion with an on-call clinician.
Note that it is acceptable and appropriate to give IV morphine and IV paracetamol before, with or after
ketamine. They have a delayed onset of action and a longer duration of action. The dose of paracetamol is
not changed; morphine should be administered slowly, and titrated to effect. Bear in mind that the
narcotic effects of morphine may be enhanced by ketamine, and the effects of ketamine may be enhanced
by morphine.
Consider giving a dose of 1-2mg IV midazolam IV at the same time as ketamine to adult patients who are
very anxious or distressed.
Example 1: 23 year old motorcyclist with an angulated tibial fracture:
1. Entonox whilst IV access is established, and whilst ketamine and morphine take effect
2. IV ketamine – up to 30mg over approximately 10 minutes to facilitate rapid analgesia, re-alignment
of the limb and splinting
3. Careful splinting of the limb, and careful handling of the patient
4. IV morphine given slower and in smaller aliquots than normal
5. IV paracetamol en-route to hospital
6. Continual reassurance and reassessment of analgesic needs, using, where possible, pain scoring.
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Example 2: 9 year old child with 25% steam burn / scald. Last known weight 25kg, in severe pain
1. Rapid cooling of the burnt area if this has not been done already
2. Aim to cover the wound with cling-film as soon as possible, using appropriate analgesia as needed
3. Entonox, as needed whilst IV access is achieved
4. Ketamine up to 0.1mg/kg i.e. maximum dose 2.5mg / 0.25ml
Then
5. Morphine 0.1mg/kg = 2.5mg IV (2.5m of 1mg/ml solution)
6. Paracetamol 15mg/kg = 375mg IV en route
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