Pain Relief (Adults) CPG Notes

Question 1

What is the primary goal of pain relief management?

Answer 1

To reduce suffering and achieve a level of comfort for the patient.

Question 2

What is the best indicator of adequate analgesia?

Answer 2

Patient-reported comfort.

Question 3

Should pain relief be withheld from patients unable to self-report pain?

Answer 3

No. If discomfort is evident, analgesia should be considered.

Question 4

In which patients should you consider dose reduction or extended intervals?

Answer 4

Frail, elderly or small patients.

Question 5

What is the preferred approach to analgesia?

Answer 5

Multi-modal analgesia – combining small doses of different agents.

Question 6

When should ALS paramedics consult?

Answer 6

If the maximum dose of opioids or ketamine has been reached but the patient remains in pain.

Question 7

Preferred management for moderate pain with IV access?

Answer 7

IV Opioid + Paracetamol.

Question 8

Why is IV route preferred in elderly/frail patients?

Answer 8

More predictable effect and easier to titrate than IN.

Question 9

When is IN fentanyl or IN ketamine appropriate?

Answer 9

If IV not required, unsuccessful, or delayed.

Question 10

When is IN ketamine preferred first-line?

Answer 10

• Opioid contraindicated • Opioid tolerant • Patient declines opioids.

Question 11

When is IM morphine used?

Answer 11

If IN is contraindicated and IV not available (e.g. facial trauma).

Question 12

When is methoxyflurane preferred?

Answer 12

For procedural pain, pain with movement, or third-line adjunct.

Question 13

Should paracetamol be given with other analgesics?

Answer 13

Yes – unless contraindicated (e.g. surgery/procedural sedation).

Question 14

Preferred combination for severe pain?

Answer 14

Opioids + Ketamine.

Question 15

Is it necessary to exhaust opioids before using ketamine?

Answer 15

No – both may be started together with 3–5 min delay between.

Question 16

When can MICA use IV ketamine over IN?

Answer 16

If IV access is immediately available.

Question 17

When should ALS consult for IV ketamine?

Answer 17

If IN ketamine is inadequate.

Question 18

What non-IV options exist if access is delayed?

Answer 18

• IN fentanyl • IN ketamine • methoxyflurane • IM morphine.

Question 19

Is paracetamol suitable in severe pain?

Answer 19

Yes, but may be impractical (e.g. surgery required).

Question 20

What is considered moderate procedural pain?

Answer 20

Minor fracture splinting, dislocation reduction, stretcher transfer.

Question 21

What is severe procedural pain?

Answer 21

Manipulation or extrication in severe MSK injury.

Question 22

Can ketamine be used for ACS chest pain?

Answer 22

No – contraindicated.

Question 23

If IV access not successful, how should ACS pain be managed?

Answer 23

IN fentanyl, or if unavailable: IM morphine/fentanyl ± methoxyflurane.

Question 24

How does fentanyl compare to morphine?

Answer 24

Equal efficacy, but fentanyl has favourable pharmacokinetics.

Question 25

Preferred situations for fentanyl?

Answer 25

• Morphine contraindicated • Short duration needed • Hypotension • Nausea • Severe headache.

Question 26

When is IM fentanyl preferred over IM morphine?

Answer 26

If morphine is contraindicated (e.g. allergy).

Question 27

Use caution with ketamine in which patients?

Answer 27

Patients with psychosis or history of mental health conditions.

Question 28

In elderly or frail patients, what is preferred over IN ketamine?

Answer 28

IN fentanyl, due to fewer side effects.

Question 29

Can ketamine be used for non-traumatic pain?

Answer 29

Yes – e.g., renal colic.

Question 30

What if no IV or IN route is available for ketamine?

Answer 30

Use IM route with IV dose.

Question 31

What is the max volume per nostril for IN medications?

Answer 31

1 mL per nostril.

Question 32

Should you add extra volume when using MAD device?

Answer 32

Not routinely; only 0.1 mL for very small doses.

Question 33

Why split the dose between nostrils?

Answer 33

To maximise absorption.

Question 34

What is the minimum frequency of monitoring?

Answer 34

Every 15 minutes.

Question 35

What are the required obs in moderate/severe pain?

Answer 35

• Airway • RR • SpO₂ • HR • BP • SAT score.

Question 36

What to do if SAT < 0 (sedation)?

Answer 36

Start ETCO₂, line-of-sight monitoring, and increase vital sign frequency.

Question 37

What to do for opioid-induced respiratory depression?

Answer 37

Titrate IV Naloxone per CPG A0722, avoid complete reversal.

Question 38

How to manage ketamine hypersalivation?

Answer 38

Suction, and Atropine 600 mcg IV/IM (MICA only) if severe.

Question 39

What are emergence reactions and how to prevent them?

Answer 39

Hallucinations/behavioural disturbance – minimise by slow IV push and reassurance.

Question 40

What drug may be used for persistent emergence reactions?

Answer 40

Midazolam 0.5–1 mg IV (ALS – consult only).

Question 41

How is a ketamine infusion prepared?

Answer 41

50 mg ketamine in 50 mL Normal Saline (1 mg/mL).

Question 42

What is the infusion dose range?

Answer 42

0.1–0.3 mg/kg/hr.

Question 43

Why does the guideline include expanded analgesic options?

Answer 43

Due to COVID-related supply issues, including MAD shortages.

Question 44

What is the minimum monitoring equipment for wilderness analgesia?

Answer 44

Manual BP cuff, stethoscope, pulse oximeter.

Question 45

Which paramedics can use the AAV pain relief guideline?

Answer 45

Wilderness response paramedics, if trained and credentialed.