BLS Fentanyl

A new article* published in Prehospital Emergency Care  (on-line April 8, 2016), concludes that Basic EMTs can safely give subcutaneous Fentanyl for acute pain in the prehospital setting.

*Subcutaneous Fentanyl: A Novel Approach for Pain Management in a Rural and Suburban Prehospital Setting

BLS EMTs in Canada received a four hour training course, and then were permitted to administer a maximum first dose of Fentanyl 1.5 mcg/kg for patients between 14 and 70 who had a pain scale of 7 or greater.  Patients over 70 could receive a maximum first dose of 50 mcgs.  Both the EMT and the patient had to agree that pain medicine would be given and the EMT  had to obtain permission from the on-line medical control MD prior to administration.

In the study,  284 patients recieved Subcutaneous Fentanyl.  Pain scales decreased significantly and there were no major side effects.  42.9 % of patients had relief of greater than 3 points.  38.6% of the patients received the Fentanyl for pain caused by trauma, 28.1% for abdominal pain, and 19.3% for back and neck pain.

The study interests me for two reasons.

First, I am intriqued by the choice of the subcutaneous route for Fentanyl.  We can give it intravenously (IV), intramuscularly (IM) or intranasally (IN).  I have mainly given it either IV or IN.  I have only given it IM a time or two.  I prefer the IV route as the bioavailability is 100%, and it provides quick, effective pain relief.  The one drawback is occasionally if I push it a little too fast, it can make the patient nauseous.  I have observed very little Fentanyl-induced hypotension in my patients, and when I do, it is always transient.  I do IN in most children and when I can’t get an IV.  While sometimes IN works great, other times, the patient finds it very unpleasant.  Some of the drug actually ends up in the back of the throat, and sometimes if I don’t push briskly enough, it doesn’t completely atomize and I see it run out of the nose.

As far as IM versus SQ, perhaps SQ because the absorption should be slower may cause less side effects than IM?  It is certainly a possibility.    I have never made anyone nauseous with IN Fentanyl.  Perhaps the same might be true with SQ, with the added benefit of greater bioavailability.  I would still use IN Fentanyl for kids with a fear of a needle.

My second interest is the BLS use of a narcotic.  I am all for this because I don’t think it requires great assessment skills to tell if someone with a broken leg is in pain.  The medical control caveat and a limit in the amount increases its safety.

One important caveat to note here is that the Canadian EMT-B is more advanced than the American EMT-B, so it may not directly relate to our EMTs, but I think it is still a conversation starter.

All the studies to date show we do a pretty poor job of prehospital analgesia.  The reasons for this can range from onerous narcotic usage /exchange policies to provider laziness to lack of education about the benefits of pain management to lack of paramedic responding to the call.  I think the latter is the chief reason.  For tiered systems, ALS is often not dispatched to calls for low falls, which are a likely source for fractures, particularly  hip fractures.

At my EMS coordinator hospital job, I have kept track of hip fractures and pain management for several years, and I can tell you that the makeup of a town’s EMS system has a huge impact on whether or not elderly with hip fractures get prehospital pain medicine.  In one of the wealthiest towns in our state, a few years ago not a single one of 34 patients with a hip fracture received analgesia because every low fall response generated a BLS only crew.  We have been pushing pain management and both encouraging BLS to call for pain management and ALS to not make BLS feel badly for calling for it.  This has improved the number of people getting analgesia, but in towns with tiered response, the analgesia rate is far lower than towns where a medic is on every ambulance.  Our best town has a 70% analgesia rate versus 20% in the tiered town I mentioned that uses fly car medics and BLS ambulances.

I believe that ALS and BLS should not be divided along the lines of invasive intervention and medication, but only along the lines of what can they do safely will proven benefit to the patient.  Defibrillation, epi-pen, CPAP, Narcan, and (I now add) Fentanyl SQ (with medical control approval), should be provided by BLS crews who have had the appropriate training, and medical oversight.  This will benefit our patients and improve our EMS systems.

8 Comments

  • Don says:

    I would like to see you go more into depth about where the line is drawn. When you add enough interventions, and then you add up all the training, they might as well go get their Medic. I know that seems simplistic, and maybe even protectionist, but I have concerns about long term affects of cook book, algorithmic treatment by basics. It this, than this etc…

    • Carol Pierce says:

      I agree with Don but with one additional question: Does all this extra training equate to more money for the EMT-B? I ‘ll bet it doesn’t…

    • medicscribe says:

      Hi Don-

      I think I will write a post on skill creep. It is a legitimate argument against BLS expansion. briefly, I think BLS and ALS need complete redefinition. That is difficult. Many are afraid adding too many things to BLS will prevent areas from getting paramedics. I’ll elaborate more in the new post — in a few days.

      • Don says:

        Look forward to it. It is a conversation we have been having in my system as we look at the proper Basic to Paramedic mix.

  • Dan says:

    Peter, how would this compare to nitrous oxide? If the delivery system was hand-held by the patient (so if they started losing consciousness the mask would fall away from their face) would this be on par as far as safety and effectiveness?

    • medicscribe says:

      Don’t know much about nitrous oxide -it is not used around here. I think it is a reasonable alternative from what I have read.

  • Thomas says:

    Expecting a wage increment for every new drug is folly. That said, in Ontario and according to the national competency profile, entry level practice is referred to as a Primary Care Paramedic not EMT-B. This requires two years of emergency medicine study at a community college and includes the IVP route for some medication delivery. Starting annual salary for a PCP in my system is not less than $70,000. Sacrifice everything, accept every regular and overtime shift offered and you might gross $100,000. All this a sidebar to the primary discussion, but since someone raised the question…

  • Casey Rowed says:

    Loved this article as well as your BLS Skill creep article.

    Just some information about Canada where this issue is of supreme interest in our paramedic system.

    I am a Primary Care Paramedic (PCP) in the Province of Ontario, which really is in no way similar to an EMT-B in the US. To my knowledge we don’t actually use the EMT-B designation in Canada. In the western provinces we use EMT-A (EMT Ambulance). I was trying to access the Full text article to see where this study was conducted I was curious which system was using the EMT-B designation.

    In Ontario the entry level is PCP, we are trained 2 years full time and most PCPs in the province of Ontario have a bachelor’s degree prior to their PCP training (though it is not a requirement).

    ACP (Similar to EMT-P) is only one additional year. So the line is very fine indeed on where BLS and ALS divide. In fact if you were to remove intubation and advanced cardiac drugs, the two designations would be identical in scope.

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