1. Standards

   Class I data regarding management of pain in the prehospital setting is insufficient to support a standard of treatment.

2. Guidelines

   Evidence regarding management of pain in the prehospital setting does not exist to support guidelines on this topic.

3. Options
   1. There are valid reasons to sedate traumatic brain injury (TBI) patients (i.e. to reduce the risk of further harm to self or others and to facilitate evaluation or evacuation) and analgesic medications are a standard part of most sedative regimens. In this case, analgesic medications should be administered in small incremental doses and with appropriate physiologic monitoring of blood pressure, oxygenation (arterial partial oxygen pressure or arterial blood oxygen saturation [PaO₂ or SaO₂]), and ventilation (carbon dioxide partial pressure or end-tidal carbon dioxide [pCO₂ or EtCO₂]).
   2. There is no scientific data or physiologic evidence to support a hypothesis that pain relief improves outcomes in TBI patients, but there is some evidence to support the possibility that the most commonly available analgesic medications (including opiates and Ketamine) increase intracranial pressure (ICP) and may thereby be harmful. Therefore, withholding analgesics from TBI patients who cannot self-score pain (Glasgow Coma Scale score [GCS] <13; see the National Guideline Clearinghouse [NGC] summary of the Brain Trauma Foundation [BTF] Guidelines for the field management of combat-related head trauma. Assessment: Glasgow Coma Scale scoring and assessment of pupils) for short periods in the prehospital phase, where monitoring is unavailable, is a reasonable option.

Summary

There may be valid reasons for wanting to control pain in the prehospital setting if it contributes to anxiety or to harmful activity but there is simply no evidence to indicate whether this is helpful or harmful in this setting. The Hippocratic Rule to "First Do No Harm" should therefore guide commonplace practice. Cautious discriminate use with as much physiologic monitoring as possible is advised.

Pain management for TBI patients in the prehospital setting should be guided by the following principles:

1. In the case of a minor closed head injury (GCS 13–15), a subjective assessment scale should be used before administering any analgesic and again before each additional dose. The goal should be to reduce pain to a level so that the patient remains comfortable but is not obtunded by the medication.
2. In addition to effective pain relief, the ideal analgesic must not alter vital signs, hide complications, or cause delay in therapeutic decision-making.
3. Analgesics should always be administered in small incremental doses.
4. Monitoring should not be limited to intermittent manual observation; the paramedic must be able to use, interpret, and act upon the data derived from patient assessment and monitoring technology to help ensure a positive outcome for the patient.
5. Hypotension (systolic blood pressure [SBP] <90 mm Hg) must be avoided or corrected immediately by administering IV fluids. SBP should be monitored as frequently as possible or continuously. (See NGC summary of the BTF Guidelines for the field management of combat-related head trauma. Treatment: fluid resuscitation).
6. Oxygen saturation should be monitored as frequently as possible or continuously. Hypoxemia (apnea, cyanosis, or oxygen saturation [SaO₂] <90%) must be avoided, if possible, or corrected immediately by administering supplemental oxygen. (See the NGC summary of the BTF Guidelines for the field management of combat-related head trauma. Treatment: airway, ventilation, and oxygenation).
7. End-tidal carbon dioxide (EtCO₂) should be monitored as frequently as possible or continuously. Hypocapnea with hypercarbia (respiratory depression with rise in EtCO₂) causes cerebral vasodilatation and subsequent increased intracranial pressure that must be avoided, if possible, or corrected immediately by administering small incremental doses of Narcan or by assisting ventilation with a bag-valve-mask device or by intubating and placing the patient on a ventilator. (See the NGC summary of the BTF Guidelines for the field management of combat-related head trauma. Treatment: airway, ventilation, and oxygenation).

Definitions:

Classes of Evidence

Class I: Evidence from good quality randomized controlled trials (RCT)

Class II: Evidence from moderate or poor quality RCT, good quality cohort, or good quality case-control studies

Class III: Evidence from moderate or poor quality cohort; or moderate or poor quality case-control; or case series, databases, or registries

Degrees of Certainty

Standards: Reflect a high degree of clinical certainty as indicated by the scientific evidence available (supported by Class I evidence).

Guidelines: Reflect a moderate degree of clinical certainty as indicated by the scientific evidence available (supported by Class II evidence).

Options: Reflect unclear clinical certainty as indicated by the scientific evidence available (supported by Class III evidence).

Electronic copies: Available in Portable Document Format (PDF) from the Brain Trauma Foundation Web site.

Print copies: Available from the Brain Trauma Foundation, 708 Third Avenue, New York, NY 10017

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