Acute pain management.

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

Clinical Notes

Acute pain is usually localized, can last for a few days, tends to decrease with healing and is generally related to trauma, infectious or inflammatory intercurrent disease and surgery.

Chronic pain is long-lasting, often determined by the persistence of the harmful stimulus and / or by phenomena of self-maintenance, which maintain the nociceptive stimulation even when the initial cause has disappeared or is limited.

It also joins an important emotional and psycho-relational component and limits the patient’s physical and social performance. It is represented above all by the pain that accompanies many chronic diseases (rheumatic, bone, oncological, metabolic …).

Procedural pain, which accompanies multiple diagnostic / therapeutic investigations, represents a particularly feared and stressful event in every setting (including the territorial one), situation and age; it is associated with anxiety and fear and not infrequently its presence significantly affects the perceived quality of care, as well as the quality of life.

The Joint Commission recognizes pain as the fifth vital parameter. To determine the best pain management treatment, it is essential to begin by identifying the intensity, duration and characteristics of the pain.

Such activity can be carried out using different methodologies universally recognized by the international scientific community:

1) Numeric scale VAS (Visual Analogue Scale) or (V) NRS [(Visual) Numeric Rating Scale], which allows you to measure the level of pain by assigning a value from 0 to 10.

2) FACES scale (Wong Baker), recommended for pediatric subjects who can speak

3) FLACC scale (Face, Legs, Activity, Crying, Consolability), recommended for pediatric subjects unable to speak.

4) Painaid scale, recommended for elderly people with communication difficulties

In addition, knowing the cause of patients’ pain and knowing the extent of a traumatic injury can help clinicians select specific procedural therapeutic interventions or other particular actions to manage the underlying condition to relieve pain for patients.

The characteristic of the pain (stinging, stabbing, stabbing, cramping, constricting, clamping, deep, fixed, etc.) helps the rescue worker a lot to identify the possible underlying pathology and to carry out the correct therapeutic and pharmacological response.

Acute pain is typically treated with quick-acting and effective injection pharmacotherapy, while chronic pain may require the use of long-acting drugs for multiple routes of administration or other modes of intervention. The cultural methodology for dealing with the problem in territorial rescue can follow the classic ABCDE system normally used in emergencies, in particularly in the pre-hospital one; typically the address is based on the following steps: highlighting an immediate empathic approach with the patient for a correct assessment of pain intensity (A), strongly believing in the data detected and in an analgesic approach (B), making a choice of the right analgesic strategy at that moment and in that specific case (C), carrying out the most correct treatment (D), implementing a direct therapeutic administration or delegating all actions directly to the nursing staff necessary for the improvement of analgesia and for the monitoring over time of the treated pain (E).

A: Ask / Assess

B: Believe (believe)

C: Choose (choose)

D: Deliver (administer)

E: Enable (enable) / Empower (give full powers)

Clinical approach

The approach every patient in an emergency situation must pay particular attention to pain according to a systematic clinical reasoning that can be summarized as follows:

1) Evaluate always pain as part of the patient’s overall care

2) Consider all territorial emergency patients with acute pain as candidates for analgesia, regardless of pathology and transport time interval

3) Use an age-appropriate pain scale to assess pain

a. subjects <4 years: consider the use of a valid observation scale such as the FLACC

b. subjects between 4-12 years: consider using a self-report scale, such as FACES

c. subjects> 12 years: consider using a self-report scale such as the Numerical Rating scale (NRS)

4) Use major analgesics for all patients with moderate or severe pain but with appropriate precautions in case of GCS <15, hypoxia with Sp02 <90%, signs of hypoventilation, hypotension, specific allergies, condition that prevents one-way administration specific and related contraindications

5) Always reassess all patients who have received analgesia using the appropriate age scale every 5-10 minutes, highlighting the presence of excessive sedation or other serious adverse effects (hypotension, hypoxia, allergy, etc.) and repeating the administration if pain is still present, with a posology lower than the initial significant dose.

Routes of administration

In the context of the pre-hospital emergency, international guidelines have mainly focused on the intravenous and intranasal route of administration as opposed to the oral, subcutaneous or intramuscular route, which are rarely useful in this context. Recently, the potential value of intraosseous access carried out in particular situations (difficult context, compromised anatomy, traumatic area) is also certainly recognized.

The promising and very useful inhalation route for some gases is not yet widespread, except in individual Anglo-Saxon pre-hospital situations, which has so far remained confined to hospital or outpatient settings, in particular due to the difficulties in supplying gases available so far.

Analgesia carried out through systemic pharmacology influences one of the different biochemical pathways of the pain control centers. Many non-narcotic analgesics inhibit cyclooxyenase, the enzymes responsible for the formation of prostaglandin, prostacyclin and thromboxane. Opioids mimic the endogenous peptides of opiates. They bind to one of the three main classes of opioid receptors (mu, kappa, delta) to produce mediated analgesia.

Medicines used

In the pre-hospital setting, non-narcotic analgesics are used for mild or moderate pain (eg paracetamol, ketorolac, ibuprofen, ketoprofen, indometacin);

X for moderate to severe pain, medications are typically used instead narcotics / opioids such as morphine, fentanyl, sufentanyl, tramadol, or sedo analgesics such as ketamine.

In emergencies for acute pain in the pre-hospital setting, the therapeutic choices are modulated according to the pain assessment:

1) Pain score 0: Report the absence of pain on the rescue card.

2) Pain score 1-3 analgesia:

Administration of Paracetamol up to 15 mg / kg intravenously by slow infusion or up to 500 mg rectally in the child. Alternatively, analgesia can be delayed in the hospital setting.

3)  Analgesia with pain score 4-6

Administration of Paracetamol up to 15 mg / kg intravenously in slow infusion or up to 500 mg rectally in the child or of Ketorolac up to 30 mg intravenously or im in the adult, or Ketoprofen 100 mg accompanied by adequate hydration.

NB: For a pain score equal to 6, in some cases, it is also possible to already administer opioid drugs.

4) Analgesia with pain score 7-10

Administration of morphine 10 mg intravenously (in refracted boluses of 2.5 mg) or phentanyl1 mcg / kg in the adult or 0.5 mcg / kg in the child intravenously slowly; this dose is repeatable on the basis of the subjective response; for both drugs, the administration can also take place via MAD (Mucosal Athomisation Device) with a doubled dosage divided in the 2 nostrils. In some cases it is possible to use Tramadol 50 mg repeatable iv / im.

Alternatively, Sufentanyl (0.1 mcg / kg) administered slowly intravenously or via MAD, also repeatable based on the subjective response, can be used.

Ketamine 0.5-1 mg / kg intramuscularly or alternatively 2-4 mg / kg intramuscularly may also be indicated (especially in children); MAD administration involves an increased dosage up to a maximum of 8 mg / kg.

The availability of methossiflurane by inhalation may be a valid alternative in moderate and severe pain (3 ml repeatable).

In the elderly and cardiopathic patients, for a safer analgesic effect, the administration of Morphine intravenously is indicated, at a dose of 2.5 mg iv, repeatable bolus as needed (maximum 20 mg / day, of which 10 mg administrable in the first hour).

The territorial logistic situation can sometimes have a negative influence due to an early administration of an analgesic drug; in fact, the patient’s high health care commitment and his instability in some cases lead to favoring other priority clinical choices as well as the difficulties of the invasive route of administration, normally privileged for the rapidity of response.

The administration of drugs, analgesics or not, per os is normally not recommended in territorial rescue for the delayed response and the risk of vomiting during transfer to the reference ED. Rapid analgesia, on the other hand, allows the patient greater comfort while waiting for a more complete evaluation and clinical assistance may be faster if the patient’s pain has decreased.

The patient’s tranquility, induced by analgesia, can sometimes mask some conditions of subsequent aggravation, which must instead be carefully monitored; moreover, badly managed analgesia in “heavy” dosages can more easily highlight the side effects of a drug.


There is still no simple and always applicable formula that defines the optimal treatment for a subject who experiences acute pain.

Failure to achieve the treatment goal within 30 minutes of a distress call in a particular patient does not automatically indicate that the treatment is of poor quality.

Equally, it seems reasonable to think that something is wrong when patients with acute painful manifestations wait longer than the “Golden Hour” to obtain a complete evaluation and adequate treatment with relief from their pain.

While assuming that a delay in analgesia is not always unjustified in some patients, any delay is still inadequate. The territorial emergency system 118 must guarantee an adequate pre-hospital treatment of “acute pain”. In fact, analgesia and sedation help to reduce the stress reactions for the patient and determine a better collaboration and greater facilitation in immobilization and in the application of advanced maneuvers to better manage the diagnostic procedure, the therapeutic treatment and assistance during transport.