The new protocol for bone and joint injuries is where you’ll find current prehospital analgesia options, at least until a dedicated pain management protocol comes out sometime next year (stay tuned!). This protocol has a couple of other non-medication features worth highlighting, though, so let’s run through it.
Like all of the other trauma-related protocols, ABCs are paramount. Following from those, BLS will focus on extremity immobilization prior to transport. Splinting specifics, including traction splinting, are listed in this section, along with instruction to attempt gentle realignment of the injured extremity if there is a concern for vascular compromise.
The ALS portion of the protocol focuses on analgesia options. Ultimately these amount to morphine and fentanyl, either of which can be given by paramedics as Standing Order only if the injury is limited to a single extremity. For an isolated extremity injury, paramedics can give up to two doses of morphine – to a maximum of 10mg total – or up to two doses of fentanyl – to a maximum of 100mcg total. Outside of the isolated extremity injury, crews will call OLMC for Discretionary Orders for one of those same medications. You may also encounter the occasional crew requesting a Discretionary Order for ketamine for pain; if you encounter such a call and decide to authorize ketamine, just be sure to be clear and specific about the dosage and route, given the numerous therapeutic ranges and uses for ketamine.
The last thing to note about this protocol is that it introduces a Medical Control Option for patellar reductions as a procedure for obvious patellar dislocations. If a crew calls OLMC requesting to perform a patellar reduction, I would say to use your discretion for authorization based on how comfortable you feel the crew is with the procedure as well as the overall condition of the patient. Just make sure that they’re describing a patellar dislocation and not a knee dislocation!
That’s all there is for this week, no…bones…about it!
Okay bye.
www.nycremsco.org or the protocol binder for more.
Dave