Remote Primary Health Care Manuals

Pain management (acute) ⚠️

  • Acute (nociceptive) pain usually has an obvious cause (eg burn, impact injury, appendicitis) and is expected to get better with tissue healing
  • Pain treatment involves the use of non-pharmacological (eg heat or ice packs) and pharmacological (eg analgesics) interventions
  • Treatment aims to provide comfort rather than total resolution (stopping) of pain
  • Always consider comorbidities, side effects and drug interactions when managing pain
  • Good response to analgesia does not exclude significant infection or illness
Red Flags — Urgent Medical Consult Medical Consult
  • Serious pain
  • Person asking for opioid medications prescribed elsewhere
  • Seeking opioids for dependency issues
  • Pregnancy
  • Neuropathic (nerve), somatic (bone, muscle, skin), visceral (organ) or chronic pain presentations
  • Frequent presentations for simple analgesia (eg paracetamol)

Ask

  • When did the pain start, how long
  • Where does it hurt. More than one place, does it move
  • All the time, coming and going, if ever completely comfortable
  • Had it before, what happened then
  • Dull, sharp, cramping, squeezing pain or discomfort
  • What they think causes pain
  • What makes it worse, eg movement, rest, time of day
  • What makes it better, eg rest, medicine, ice, heat, activity
  • About pain score on a scale of 0 no pain to 10 worst ever or use face scale — Figure 7.1

Figure 7.1  

Series of faces with expressions indicating levels of pain: 0 no pain; 1 little pain; 2 more pain; 3 big pain.

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • U/A, pregnancy test 
  • Head-to-toe exam

Do

  • Treat underlying condition or injury
  • Communicate with patient and family to reduce fear and anxiety
  • Position for comfort
  • Consider heat and/or cold therapies
  • Consider relaxation and/or distraction techniques
  • Give pain relief — check specific requirements for each medicine
  • Reassess pain level regularly

Pain Medicines

You must know your organisation's policy about which pain medications can be initiated (started) by a RN or ATSIHP 

Paracetamol

  • Do not give for fever if no pain or discomfort or child not miserable — can make some viral sicknesses last longer
  • If ongoing pain — regular doses are better than waiting for pain to get very bad — consider using slow-release paracetamol
  • Double dose can be given at night — then no more for next 8 hours

Adult

  • Do not give more than 8 tablets (500mg) or 6 tablets (665mg) in 24 hours
  • If fasting, known liver disease, regular or heavy user of alcohol — reduce dose to 4–6 tablets  (500mg) in 24 hours

Child

  • Child dose — 15mg/kg/dose every 4 hours
  • Syrups comes in different strengths — always check the bottle
  • If dose for weight is more than the dose for age — use the dose for age
  • No more than 6 doses in 24 hours for first 2 days THEN 4 doses a day
  • If child needs stronger pain relief — medical consult
  • Suppositories can be used if adult or child can’t or won’t take oral paracetamol
    • Come in 125mg, 250mg and 500mg strengths
    • Use 1 or combination for right dose — Table 7.1
    • If suppositories not available — paracetamol syrup can be given in rectum using lubricated 2mL syringe. Same dose as oral

Table 7.1 Paracetamol doses  

Age

Weight (kg)

Syrup* (mL)
(24mg/mL or 120mg/5mL)

Syrup (mL)
(48mg/mL or 240mg/5mL)

Tablet
(500mg)

Suppository
(mg)

Newborn

3.3kg

2.2mL

1.1mL

–

–

3 months

6.2kg

4mL

2mL

–

–

6 months

7.6kg

4.8mL

2.4mL

–

125mg

1 year

9kg

5.6mL

2.8mL

–

125mg

2 years

12kg

7.6mL

3.8mL

–

125mg

4 years

16kg

–

5mL

½

250mg

6 years

20kg

–

6.4mL

½

250mg

8 years

25kg

–

7.8mL

1

500mg

10 years

32kg

–

10mL

1

500mg

12 years

40kg

–

12.5mL

1

500mg

14 years and over

50kg or more

–

–

2

1,000mg (1g)

* If 15kg or over — recommend to use smaller dose of stronger syrup

Oral non-steroidal anti-inflammatory drugs (NSAIDs)

Contraindications for NSAIDs 

Paracetamol-codeine (500mg+30mg)

Codeine (opioid) may make person drowsy, constipated — advise extra fluids and high fibre diet

  • Do not use for children under 12 years
  • Do not give more than maximum daily dose of paracetamol (paracetamol alone and/or paracetamol-codeine) in 24 hour period (adults 4g)

Opioids

Aim of opioid injection treatment is to stop severe pain as quickly as possible without sedating person — some discomfort may remain

Always have naloxone available when you give an opioid IV or SC  

Naloxone

  • Patients who have had naloxone administered require close observation — sedation score, pain score, respiratory rate and BP every 5 minutes for 15 minutes and then every 15 minutes for 2 hours
  • If the patient has had sustained release opioids, they may need a naloxone infusion

Adults

  • Draw up 400microgram per mL ampoule and add 3mL 0.9% sodium chloride for injection (normal saline) = 100microgram per mL
  • Give naloxone 100microgram (1mL) every 3 to 5 minutes until sedation score is 2 or less and the respiratory rate is greater than 10 breaths per minute

Children

  •  Give naloxone 10micrograms (0.01mg) per kg /dose up to 200micrograms (0.2 mg) — dose

Do first

Before giving opioids

  • Medical consult — if this will cause serious delay in treatment may give morphine only THEN do medical consult as soon as possible
  • Assess level of pain on a scale of 0 no pain to 10 worst ever pain
  • Check patient’s sedation score 
  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL

Do

  • Patient must be continuously monitored — repeat observations every 5 minutes for 15 minutes THEN every 15 minutes for 1 hour after last opioid dose given

Table 7.2   Sedation Score 

Score

Description

Required action

0

Awake
  • No action required, continue to observe

1

Mildly drowsy, easy to rouse, able to keep eyes open for more than 10 seconds
  • Continue to observe for increasing sedation

2

Moderately drowsy, easily roused, unable to keep eyes open for 10 seconds
  • Increase frequency of observation to every 15 minutes until sedation score 1 or 0
  • Maintain close observation of the patient
  • Do not give any additional opioids
  • Give oxygen via nasal prongs at 2L/min

3

Severely drowsy, difficult to rouse — may have respiratory depression
  • Life support — DRS ABC if needed
  • Give oxygen via non-rebreather mask 10–15 L/min to maintain oxygen saturations above 93% (if COPD 88–92%) 
  • Give naloxone
  • Medical consult
  • Do not give any opioids until sedation score less than 2 and respiratory rate greater than 10 breaths per minute

Table 7.3   Side effects of opioid administration  

Side effects of opioid administration

Management of side effects — medical consult

Over sedation

Close monitoring of sedation scores. Consider giving naloxone

Respiratory depression

Close monitoring of respiratory rate. Consider giving naloxone

Nausea & vomiting

Consider antiemetic

Itch

Consider non-sedating antihistamine

Acute urinary retention

Consider catherisation female , male

Constipation

Consider aperients (laxative)

Table 7.4   Acute pain relief (Adult)  

Pain level

Treatment

Mild pain (0-3)

Non-pharmacological interventions such as positioning, heat or cold packs

AND

  • Paracetamol — 500mg, 1–2 tabs, up to 4 times per day (qid) PRN (maximum 8 tablets in 24 hours)

OR if not contraindicated AND recommended in individual protocol —ibuprofen — 200mg, 1–2 tabs as needed, up to 3 times per day

Moderate pain (4-6)

Non-pharmacological interventions such as positioning, heat or cold packs

AND

  • Paracetamol — 500mg, 1–2 tabs, 4 times per day

AND if not contraindicated — ibuprofen 200mg, 1–2 tabs 3 times per day with food

AND oxycodone (IR) — 5mg, 1–2 tabs every 3 hours PRN — medical consult

OR

  • Paracetamol–codeine — 500mg+30mg, 1–2 tablets, up to 4 times per day (qid) PRN — only 2 doses can be given without a medical consult

Do not give regular paracetamol if using paracetamol-codeine 500mg+30mg

Severe pain (7–10)

Non-pharmacological interventions such as positioning, heat or cold packs

AND

Medical consult

AND if sedation score less than 2 and respiratory rate greater than 8 — morphine IV

  • Draw up morphine 10mg /1mL ampoule
  • Add 9mL normal saline to give you 10mg in 10mL or 1mg per mL

For patients younger than 70 years of age

  • Give 1 to 2mg (1–2mL) slowly (over 1 minute) every 5 minutes to a maximum of 10 mg

For patients older than 70 years of age

  • Give 0.5 to 1mg (0.5–1mL) slowly (over 1 minute) every 5 minutes to a maximum of 10mg
  • Morphine IM — give straight from ampoule per medical consult
  • Morphine subcut — put in subcutaneous cannula into fatty tissue on outer aspect of upper arm OR front of thigh OR side of belly and secure well

For patients younger than 70 years of age — 2.5 to 10mg s/c as a single dose

For patients older than 70 years of age — 2.5 to 5mg s/c as a single dose