Undertreated Pain
Objective: Oligoanalgesia means pain is undertreated. Ask for a pain score. Offer the analgesia the protocol allows. Reassess. Do not skip treatment because the transport is short. This page does not list milligrams.
Why this matters
Oligoanalgesia means we undertreat pain. The pattern is no score, no drug, or one very small dose and no recheck.
Consider analgesia for acute traumatic pain no matter how short the transport is. Assess. Treat. Reassess. Fear of hiding the exam, and fear of the airway, both drive undertreatment. The injury is still there. The patient is still in pain. This page does not list milligrams. Do not invent a fentanyl dose.
- Ask for a number, or use the scale that fits the patient’s age. Write it down. Ask again after the drug.
- A short transport time is not a contraindication. The hospital can still examine a treated patient.
- Life threats first. Then pain. Uncontrolled bleeding and an unprotected airway still come first.
- Use the drug your protocol names: an opioid, ketamine, acetaminophen, an NSAID, or intranasal fentanyl in children. This page does not list milligrams.
Clinical sequence
- Airway, breathing, circulation, and bleeding first. Then ask, what is your pain from 0 to 10? Use a faces scale, or FLACC (face, legs, activity, cry, consolability), as your service uses.
- If the patient has moderate or severe acute pain and your protocol includes analgesia, treat. Do not wait until you arrive at the hospital.
- After an opioid, watch mental status and breathing. Use waveform capnography if you have it. Naloxone is for the rare overdose of the pain dose. It is not a reason never to treat pain.
- Reassess within minutes. If the patient is still in severe pain and the protocol allows another dose, give it. Document the scores.
Teaching points
- Assess: prefer the patient’s number over your guess. Quiet people still hurt.
- Treat regardless of transport time for acute traumatic pain.
- Children with no IV: intranasal fentanyl is favored over waiting for an IV, when the protocol includes it. Your protocol sets the device and the dose.
- Reassess: one dose is not the whole job. Pain that returns is a reason to follow the repeat-dose rule, not a reason to stop.
- Ask for a pain score now.
- I am treating pain the way the protocol allows.
- I am watching breathing.
- I will ask for the score again after the drug.
Common errors
- A short transport used as the reason not to treat pain.
- No pain score anywhere on the chart.
- Withholding analgesia because you might hide the abdominal exam.
- One very small dose and no recheck.
Practice
One-minute check
With a partner: an isolated ankle fracture, pain 8 out of 10, an 8-minute transport, and stable vital signs. What do you do besides splint? Then the pain is still 8 out of 10 after one protocol dose. What is the next move? The numbers are a practice scene. They are not a dose.
Related: Fentanyl for Pain Management, Ketamine in the Field, Oral Analgesics in the Field.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language. Your protocol still decides.
- 2014 GRADE: Prehospital Analgesia in Trauma — Strong recommendation: consider analgesia regardless of transport time. Assess and repeat the dose as needed.
- Lindbeck et al. — Evidence-Based Guidelines for Prehospital Pain Management (PEC 2023) — A strong recommendation for intranasal fentanyl over intravenous opioids in children without IV access. Your protocol sets the device and the milligrams.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.