The necessity for pain relief in the acute setting is a no brainer, and with the advent of the heroin epidemic - the need to be creative and be equipped with non-narcotic alternatives like Tylenol should be top of mind for your agency. Pain management can be complex as the pharmacological selection is based on the patient, their allergies, and their hemodynamic status. Some clinicians would consider pain a fifth vital sign and something we should be trending during the transport. Others state this is old school thinking as pain shouldn't carry as much weight as BP, HR, RR. Regardless of where you stand on the issue, you should be familiar with the analgesics you carry and regularly administer.
Pain relief has some inherent risks like nausea/vomiting, hypotension, respiratory depression (more common in the narcotic drug classes) however, pain relief also has many benefits when medications are administered in a controlled setting. Analgesia reduces anxiety, improves patient satisfaction, and decreases human suffering. Lastly, Tylenol has been shown to be effective and it also comes with a great safety profile.
To assess pain experienced by our patients - we have options! We can have them rate their pain on a numeric scale (0-10). For children we can have them point to a pain rating scale that includes images. For patient who have communication barriers or for those who may be completely non-verbal -- we can look for sometimes subtle clues like grimacing, restlessness, and guarding.
IV and/or PO Tylenol has been getting some more attention as of late for the reasons described above. Acetaminophen has both analgesic and antipyretic properties with effects equivalent to those of aspirin. Its analgesic and antipyretics effects are likely the result from the inhibition of prostaglandin E2 (PGE2). It does not fall into the non-steroidal anti-inflammatory class of medications as it has no anti-inflammatory effects. Acetaminophen acts on a variant of cycloxygenase (COX3) that is only expressed in the central nervous system. Unlike aspirin, it has no effect on COX1 or COX2 and therefore, it has no effect on platelets. Acetaminophen elevates the pain threshold and readjusts the hypothalamic temperature regulatory center. One word of caution it should be used sparingly in those with known hepatic insufficiency or failure.
Most agencies dose acetaminophen for adults at around 10-15 mg/kg over 15 mins (max 1000 mg) - however, I always suggest you following your local medical director approved protocols. The maximum dose in a 24 HR period is typically 4 grams. For pediatrics the dose is similar at 15 mg/kg. Of note, many progressive agencies view PO (elixir) administration as a BLS skill.
The way healthcare professionals medicate patients has been under great scrutiny over the past several years and arguably with good reason. Specifically, the how and the why behind certain medication classes. So, I ask, has your agency considered non-opiate alternatives. Is offering nontraditional or non-IV medications seen as a deterrent? Does costs and ease of use drive your admins decision making? Maybe it is time to have a great conversation with your medical director. Just some things to ponder in this new year as we consider what the future of pre-hospital analgesia may look like!
January 29, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.