Acute pain management in ed @ nbe

Acute Pain Management in the ED
Dr. Venugopalan P.P. DA, DNB, MNAMS.MEM[GWU-US]
Director ,Emergency Medicine ,Aster-DMHC
Deputy Director ,MIMS Academy ,PG Teacher NBE
Kozhikode , Kerala , India
www.drvenu.blogspot.in

Pace 2014,August 2014 -1 to 3rd at
Chennai
Introduction
• Pain is the most common presenting
symptom in emergency departments
• More than 60 percent of ED patients have
pain as their main symptom or a major
part of their symptoms.

Introduction…
• Pain is always subjective .
• No test to prove or disprove the patient’s
pain.
• Not vital signs, a patient’s facial expressions,
or “gut instincts” can be used to invalidate a
patient’s rating of his or her pain.

Introduction…
• An unrelieved pain has deleterious effects
on “physical, physiological &
psychological” systems.
• Remarkable discomfort to the patients

Introduction…
• International accreditation agencies like
JCAHO are setting standards in
management of pain in emergency
departments.

Focus
• Define acute pain
• Brief overview of pathophysiology
• Barriers in pain management in ER settings
• Common Dos & Don'ts
• Common Pitfalls in pain management
• Strategies to improve pain management in ER
• International recommendations

Definition
Pain is ‘an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage’ or,
more simply, ‘pain is what the patient says
it hurts’
Assessment of acute and chronic pain, www. Anesthesiauk.com
Created: 5/9/2005 ,Updated: 12/1/2009

Sensory
Emotional
Cognitive
Behavioral
PAIN
Environmental
Developmental
Sociocultural
Contextual

A
C
U
T
E
C
H
R
O
N
I
C
Somatic ,Visceral or Neuropathic
PAIN

Acute Pain Chronic Pain
Cause Generally
Known
Often unknown
Duration Short -3 to 6
months
Long - more
than 6months
Behaviour Anxiety Depression
Response to
treatment
Well to
medicine
Does not
respond well
Tissue
appearance
Red White
Treatment R.I.C.E
Rest-
Ice-
Compression-
Evaluation
M.E.A.T
Movement-
Exercise-
Analgesic-
Treatment

Acute pain
• Injury or Pathologic
condition
• Resolves with inciting cause
• Nociceptors
• Release of chemicals –
leukotrienes, Bradykinins,
Serotonin, Histamine &
Thromboxanes, Substance P

Prostaglandins
• Not directly activate receptors
• Act as local mediator
• Increases sensitivity of nerve endings
• Pain and edema
Fink WA Jr, The pathophysiology of acute pain .Emerg Med Clin North
Am. May 2005;23[2]:277-284.[review]

Pace 2014 ,Chennai August 1 to 3 rd
Acute Pain

Non –
Noxious
Stimuli
Non –
Noxious
Stimuli
Pain Pain
Nociceptive
Pain
Neuropathic
Pain
Neuroplastic
Pain
Tissue
Injury
Tissue
Injury
Nerve
Injury
Pain

“Wind up”
phenomenon
Sharp localized pain
Dull diffused pain
Pain should be treated as early as possible
• Noxious stimuli cause increased
nociceptor responsiveness
• Progressive increase in dorsal horn neuron
output
• Pain amplification

When a patient in pain enters the ED he or she has
two main concerns
1.How quickly can I get relief from my pain? 

2.What is causing this pain?

The major focus of health care professionals
1. What is the
diagnosis?  

2. What is the
treatment for the
underlying disease
process?

No Pain Worst Pain
Imaginable
Visual
Analogue
Scale
The patient is shown a 10cm line marked as above. They are
asked to put a mark across the line that indicates the severity
of the pain. Doctor or Nurse then measure the distance from
“No pain “ to the mark in cm

0 1 2 3 4 5 6 7 8 9 10
No Pain Worst Pain
Imaginable
Numerical
Analogue
Scale
The patient is shown the scale above. They are
asked to indicate which number equates to the
pain they feel

Verbal Rating Scale -VRS
Five pain levels in large print
• No pain
• Mild
• Moderate
• Severe
• Unbearable

Verbal Descriptor Scale
• No pain
• Mild
• Discomforting
• Distressing
• Horrible
• Excruciating [Tanabe]

Pain assessment in children
Wong-Bakers FACES – Pain Rating Scale
Hockenberry MJ: Essentials of pediatric Nursing ed 7,st,Louis ,2005 ,Mosby
P 1301

CHOEPS 
Children’s Hospital of Eastern Ontario Pain Scale
• Crying
• Facial expression
• Verbalization
• Activity of Torso
• Touching
• Response of Lower
limbs
Score
Minimum – 4
Maximum - 13
Hennrikus:J Bone Joint Surg Am ,Volume77-A[3] March 1995.335-339

PQRST Symptom Analysis
• Presentation , Provocation & Palliative
• Quality – Sharp, Dull ,Pricking ,colicky etc
• Radiation, Region and Relieving factors
• Severity – Pain Scale
• Time of onset and Treatment received

• TENS
• Incentive spirometer
• Acupuncture
Non Pharmacological
Methods to relieve acute pain
• Splinting
• Cold pack
• Positioning
• Relaxation techniques

• Steroids
• Anticonvulsants
• Entonox
• Ketamine
Procedural Sedation
Pharmacological
Nerve blocks
Methods to relieve acute pain
• Acetaminophen
• NSAID
• Opioids
• Antidepressants

Brain
Arachidonic acid
Spinal cord
NSAIDS
Prevention
Peripheral Nerve
Nociceptor
‘Sensitizing soup’
prostaglandin
Physical Stimulus
[Heat, Pressure]
Opiates
Alpha 2 agonists
Local Anesthetics
Tissue
injury
Analgesic
therapy

‘Assessment –Treatment- Reassessment’
“Diagnosis and Treatment”
of the underlying condition
Pain relief
T
I
T
R
A
T
E

OPIOIDS regularly
Paracetamol 1gm orally or rectally /regularly q. d.. s
Severe pain
Moderate pain
Mild pain
OPIOIDS when required
Non steroidal anti inflammatory drugs
0 3 6
10
No Pain Moderate pain
Worst
Possible pain
Acute pain relief
Treatment
Chart

Mild pain
1-3
Paracetamol p.o
Ibuprofen p.o
Moderate pain 4-6
As for mild pain
+
NSAIDS p.o
or
Tramadol p.o
Severe pain 7-10
Entonox initially
or
IV morphine Titrated
Dose
Supplimented with
NSAIDS
or
Ketamine
Assess pain severity
Use Splints/Slings/ Dressings
Consider the other causes
Consider regional blocks
Acute pain treatment algorithm

Pain score
Initial Dose
Monitor
Pain score
Top up
dose
Monitor
Pain score
Top up
Pain Free
Morphine 3 mg - 1mg - 1mg - repeat till get zero pain score
Fentanyl 30 mcg - 10 mcg -10 mcg- repeat till get zero pain score
Ketamine 20 mg - 5 mg - 5 mg - 5 mg repeat as needed
Titrate ….No calculated dose
Pentazocine- Ceiling effect , Tachycardia , Hypertension

Tramadol
• Believe as safe
• Not so potent as we
think
• Convulsion
• Restlessness in Aged
• Cardio respiratory
arrest

NSAID-Non Steroidal Anti-Inflammatory Drugs

Before NSAID-Look for ABCDE
Allergy
Bronchial Asthma
Coagulation profile
Detectable Gastric Ulcers
Evaluate Kidney function

Nerve block
• Pivotal role in acute pain
management
• Reduce NSAID and Opioid use
• Very effective and get Zero pain
score
• Need skill updation
• USG made revolution in Nerve block
• Assess and document neurological
status
• Highly recommended in devastating
injuries

Pain
Sedation
Analgesia
Calls Nurse
Nurse
comes
Nurse assesses
pain
Prepare
injections
Injection
given
Absorption
Pharmacokinetics
Variables
Nurse variables
Patient Variables
PCA
PCA
S
H
O
R
T
E
N
S
The
Cycles
of
Pain
Control

PCA
Rule of Ten - Fentanyl
Concentration 10 mcg/ml
Bolus 10 mcg
Background infusion 10
mcg /mts
Lock out interval 10 mts

Pain is under treated !!
Almost always …….

Evidences  
• Patients presenting to an ED with a
complaint of pain, two-thirds never had
an assessment of their pain documented.
Todd KH et al. The Joint Commission on Accreditation of Healthcare
Organizations Pain Initiative: Are We Meeting the Standard?
Annals of Emergency Medicine. 2000. 36:4 S68

Evidences…  
• Of these patients, only one-third ever had
a re-assessment of their pain
• Upon discharge from the ED, 43 percent
of patients were still in moderate or
severe pain
Todd KH et al. The Joint Commission on Accreditation of Healthcare
Organizations Pain Initiative: Are We Meeting the Standard?
Annals of Emergency Medicine. 2000. 36:4 S68

Evidences
• Reviewed 198 patients admitted to ED
with acute pain
• 67% had documentation
• 44% received narcotics
• 60% received intramuscular doses
Wilson JE et al .Oligoanalgesia in the emergency department .An J Emerg
Med .Nov1989;7[6]:620-623[Review 198 patients]

Evidences…
• 33% of the documented cases received
suboptimal analgesia
• 69% waited more than one hour to get
analgesics
• 42% waited more than 2 hours.
Wilson JE et al .Oligoanalgesia in the emergency department .An J Emerg
Med .Nov1989;7[6]:620-623[Review 198 patients]

Evidences…
• 842 patients at 20 US Canadian hospital participated in
study to assess the current state of ED pain
management.
• Patients presented with a median NRS of 8
Knox H .Todd; Acute pain in the emergency room setting : An expert interview;
Medscape neurology & neurosurgery 05/27/2008;www.medscape.com

Evidences…
• 41% - no change in the pain score in ED
• 34% -discharged without any change in
pain score
• 45% patients discharged with NRS 4-7 and
29% patients with NRS 8-10.
Knox H .Todd; Acute pain in the emergency room setting : An expert interview;
Medscape neurology & neurosurgery 05/27/2008;www.medscape.com

• Under assessed
•Under managed
Emergency
Department
ANZCA .statement on pateints’ rights to pain management .ANZCA
ps 45;2001,available at www.anzca.edu.au
Acute Pain- The “ TRUTH”
• The Fifth Vital sign
• Relief from pain is a “Fundamental Right”
“Declaration of Montreal”2010

Related
Health Care system
Health Care provider
Patient
Agency for Healthcare Research and Quality .[2005] Management of
cancer symptoms :Pain, depression and fatigue .www.ahrq.gov/downlods/pub/
evidence
Pain
B
A
R
R
I
E
R
S
Emergency Department

Martin D et al .Barriers to pain management in emergency department ;
emergency nurse ,vol 15 no 9, feb 2008. 30-34;
Healthcare system related
• Lack of time
• ED overcrowding
• Poor levels of clinician education
• Inadequate policy and standards
• Suboptimal use of analgesics

Healthcare provider related barriers
• Subjective nature of pain
• Attitude
• Beliefs
• Poor understandings / false beliefs on
using opiates like morphine
World Health Organization [1986]Cancer pain relief .WHO. Geneva

Patient related barriers
• Misconceptions
• Society’s traditional views
• Fear of consequences
• Fatalism
• Communication fear
• Alcohol and drugsMartin D et al .Barriers to pain management in emergency department ;
emergency nurse ,vol 15 no 9, feb 2008. 30-34;

10 dos 10 donts
10
Pitfalls
Acute Pain management

Ten Do’s Ten Don’ts
Ten’s ‘N’ Acute Pain
P
A
I
N

Acute Pain – 10 – Do’s
1. Believe the patient’s assessment of pain
2. Give adequate doses of analgesics [ED & Disposal] and
document the patient’s response
3. Prevent pain before it begins
4. Treat aggressively
Titrate ...Titrate… Titrate…

Acute Pain – 10 – Do’s…
5. Opioids are very useful in both acute and
chronic pain*
6. Anticipate side effects
7. Treat by the clock
*Consensus statement ,the American Pain Society and the American
Academy of Pain Management statement .Clinical journal of Pain .
1997.Mar.13[1]:6-8

Acute Pain – 10 – Do’s…
8.Write prescriptions wisely
[Quantity & Strength in both Letters and Numbers]
9.Refer patients appropriately to primary care provider or
pain clinician
10.Prescribe Patient Controlled Analgesia [PCA]

Acute Pain – 10 – Don’ts
1. Intramuscular
injections
2. Meperidine
3. Sedative or anti-
emetic along with
analgesics
4. Term ‘Narcotics’
Avoid…Avoid ..Avoid

Acute Pain – 10 – Don’ts…
5. Codeine - Very weak
opioids
6. Propoxyphene – Very
weak analgesic
7. Treating acute and
chronic pain in the same
pace
8. Prescribing PRN schedule
Avoid …Avoid…Avoid

Acute Pain – 10 – Don’ts…
9. Holding Opioids due
to fear
10.Holding pain
treatment to reach a
diagnosis.
No need a ‘Diagnosis’
to control pain
Silen W. Cope’s Early Diagnosis of the Acute Abdomen.2000

Acute Pain
management-
ten pitfalls

2nd Eurasian International Congress on Emergency Medicine 28th – 31st Nov 2008 at Antalya Turkey
Acute Pain- 10 – Pitfalls
• “The patient had abdominal pain , But I didn't give any pain
medication because I did not want to mask the exam”
1.Comfortable patient yields more information
2.Pain relief will not mask serious pathology
Emergency medicine practice :An evidence based approach to emergency
Medicine .EBMedPractice.net; July 2006;8[7].
One

Acute Pain- 10 – Pitfalls..
• “The vital signs were normal , so even though he said he was
in pain there wasn't any evidence that it was true.”
1.Vital signs are not a reliable predictor of pain
severity
2.Patient’s version is most reliable
Two

• “I didn’t give narcotics because I was afraid he would get
addicted”
No evidence to support acute pain management causes
narcotic addiction
Three

• “The patient was not in pain at the time of discharge, so pain
control did not need to be addressed”
1.Patient should be discharged with pain killers
2.Some disease process may increase after discharge
to cause pain
Four

• “Patient was an IV drug abuser; I knew he was just looking for
pain medication, so I sent him right out”
1.IV drug abusers at risk for complications like epidural
abscess , necrotizing fascitis etc.
2.Need proper ED evaluation
F
I
V
E

• “The parents did not think the child was in pain, so I stopped
thinking about pain control at that point”
1.Parents may underestimate pain
2.Look for signs – grimace, guarding etc
3.Child’s pain is serious
S
I
X

• “She was an IV drug abuser, so I gave her pain meds I would
have given anyone else. When pain wasn't controlled I told her
that was her problem”
1.Tolerance to opiates may need more medications
2.Actual dose should not be the primary concern
S
E
V
E
N

• “I made the diagnosis, which is my priority. What difference
does it make if I treated their pain?”
1.Stabilizing patient’s pain should also be in the priority
2.No need a diagnosis to initiate pain meds
E
I
G
H
T

• “The patient was too demented to even know if he was in
pain, he didn’t need medication”
Non verbal patients may be in significant pain.
ED physicians should be attuned to other signs
N
I
N
E

• “She was allergic to everything but meperidine, that’s when I
knew she was a drug- seeker”
1.When patients list allergies , physician should
explore what is meant
2.Should evaluate pathology and need for pain meds.
T
E
N

Acute Pain –Strategies
1. Prioritise pain
management
2. Mandatory pain
assessments
3. Ongoing education-
Patients & Clinicians
4. Ongoing evaluation of
strategies Rupp T et al , Inadequate analgesia in the emergency medicine. Annals of
Emergency medicine 2004;43,4,494-503

International guidelines
Pain assessment
standards
[ Joint Commission on
Accreditation of
Health Care
Organizations –
JCAHCO 2001] USA
JCAHO 2001.Revised pain management standards.www.jointcommission.
org/standards/

International guidelines…
Musculoskeletal pain
management guidelines
[National Health and
Medical Research Council
-2003 ]-Australia
Evidence- based management of acute musculoskeletal pain .
www.nhmrc.gov/publications/ synopses/_files/cp94.pdf. 2003

International guidelines…
Recent guidelines
[British Association for
Accident and Emergency
Medicine -2007] UK
Clinical effectiveness committee audit standards for Emergency Departments.
www.emergencymed.org.uk/BAEM/CEC/assets/summory_of_standards_Jan
2007.

Conclusion
Relieving from pain is the fundamental
right of the patients.
Physician’s lacunae should not end up in
under treated pain .

Conclusion…
International standards insist
appropriate pain management protocols
for ED setting.
ER physicians should place and follow a
pain free ER concept.

Travel to zero pain ……You can do a lot!!!!

Thank
Thanks a lot
Call 9847054747
Mail drvenugopalpp@gmail.com

Acute pain management in ed @ nbe

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