Pain Management in the Emergency Department

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Pain Management in the Emergency Department

• AJEM 2004 March 2251-57
• Presented by R2 ???

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Introduction

• Recent regulatory and legal scrutiny raised
  concerns about the over and undertreatment of
  pain in the emergency department
• Purposes of this article
• offers a synopsis of the pitfalls associated
  with ED pain management and provides
  recommendations for selected conditions

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Issues in analgesics use

• Need ?
• Suffering far outweighs he diagnostic or
  protective value of pain
• Addiction?
• Drugs?
• Allergy?

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Unified in support of appropriate prescribing for
pain
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Understanding pain

• Purposeful pain
• Ex acute pain that identifies an obvious injury
  and serves to raise vigilance and isolation of an
  affected area
• Purposeless pain
• Ex post-herpetic neuralgia with chronic
  suffering that remains as a ghost of an otherwise
  healed episode of zoster

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Understanding pain

• Acute pan
• Usually associated with trauma and known
  pathological conditions
• Generally resolves once the condition resolves
• nociceptors fire repetitively
• Response to opioids and NSAID
• Lower risk in drug abuse

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Understanding pain

• Chronic pain
• Nervous system malfunction
• Prolong exposure to tissue injury can sensitize
  certain nerves in pain-singnaling pathway
• These nerves continue sending pain signals to the
  brain after the pain-causing condition has
  resolved
• Degenerative condition
• Neoplasm
• Multiple medications may be used
• TCAs, anticonvulsants, NSAIDs, and opioids

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Understanding the problems
Opioid contract 1.Placed increased
responsibility on the patient 2.only one
physician can prescribed opioid to the
patient 3.contact the primary physician in
special conditins

• Analgesics use in acute pain
• mask diagnostic PE finding ( abdominal pain)
• Analgesics use in chronic pain
• Abuser
• Use medications other than opioid, ex NSAIDs
• Restriction of opioid contract by explanation
• Withdraw status
• Taper the dosage in 10-15 every 48 hours
• Clonidine, Cyclobenzaprie, Dicyclopmine,
  anxialytic, antidepressants

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Assessing prescription drug abuse
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Treating chronic painful conditions in the ED

• Many common chronic pain conditions have no known
  pathophysiology
• Disturbance of the CNS
• Sensitization of neurons
• Abnormal sprouting of neurons into pain pathway
• Disinhibition
• Headache and backache are 2 of the most common in
  the ED

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Headache

• Chronic severe headache with comorbids of
  affective disorder, substance abuse, polypharmacy
  effects ( rebound or daily headache
• Belgrade et al
• Compared the effectiveness of dihydroergotamine,
  meperidine, butorphanol
• Meperidine is associated with least pain
  reduction, produce sedation and orthostatic
  hypotension, prolonged ED stay
• Alternatives NSAIDs, Sumatriptan,
  Metoclopramide, Chlopromazine, Decadron,
  intrnasal Lidocain

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Low back pain

• Amount the 10 leading causes for ED visit
• Usually acute and self-limited
• Often recur and become chronic in 5-10
• Opioid are rarely necessary
• Deyo et al
• Approximately 90 of acute low back pain resolve
  within 3 months
• Short course of bed rest (2 days), analgesics
  (NSAID Acetaminophen) and OPD F/U are
  reasonable management

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Low back pain

• Red flags (warning signs) of low back pain
• Need prompt image study and further investigation

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In chronic low back pain

• Wadells criteria for r/o surgical candidate
  (composed of psychobehavior component)

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Sickle cell disease

• Patients presenting pain secondary to sickle cell
  disease
• Vassooclussive crisis provoked by severe
  infection, change of temperature, dehydration,
  high altitude, stress, MC.
• Platt et al poor pain control is associated
  with higher morbidity and motality
• Gonzalez et al PCA was a more acceptable tx

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Renal colic

• Affects 2-5 of the population
• Vecchiet et al
• Persistent hypersensitivity to painful
  experimental electrical stimulation of the
  affected side after episode of renal colic
• Larkin et al
• Keto im was more effective than meperidine and
  earlier discharge

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Use analgesics in acute abdominal pain

• General opinions of EPs
• Clinical practice
• Dose it impair diagnosis?
• Is narcotics safe?
• What about for children?

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EPs opinions in if analgesics mask diagnostic
PE findings

• Nissman et al
• Mathod telephone survey
• Size 60 US hospitals EPs
• Result 59/60 (98) give analgesics before
  surgical evaluation
• Patient discomfort takes precedence (88)
• Literature supports the practice to be save (86)
• Am J Surg. 2003 Apr185(4)291-6

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Clinical practice of analgesics in acute
abdominal pain

• Wolfe et al
• Method mailed questionnaire to 1000 US EPs
• Size 440
• Result 85 say no, but 76 give analgesics
  after surgical evaluation
• Am J Emerg Med. 2000 May18(3)250-3

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Dose it impair diagnosis?

• Thomas et al
• Purpose Effect on diagnostic efficiency of
  analgesia for undifferentiated abdominal pain.
• Method medline search
• SizeEight trials
• Result no study show association between
  analgesics use and diagnostic impairment
• Br J Surg. 2003 Jan90(1)5-9.

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Is narcotics safe?

• McHale et al
• Narcotic analgesics in acute abdomen
• Method reviewed all the prospective trials that
  investigated the safety, adverse affects, and
  ultimate outcome in patients with acute abdominal
  pain receiving narcotic analgesia within the
  emergency department (ED)
• Result no adverse outcomes or delays in
  diagnosis
• Conclusions it is safe and humane to administer
  narcotic pain relief to patients presenting to
  the ED with acute abdominal pain
• Eur J Emerg Med. 2001 Jun8(2)131-6

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What about for children?

• Kim MK et al
• Method a randomized, double-blind,
  placebo-controlled (0.1 mg/kg morphine and the
  same volume NS) clinical trial, record PE
  findings before (EP) and after (surgeon)
  analgesic
• Size 29 received morphine, 31 received NS
• Result significant pain reduction without
  significant diagnostic accuracy change

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Conclusion

• Pain relief is an essential component of care in
  emergency department
• As a guiding principle of medicine and core
  covenant with our patients, every EP must embrace
  providing timely and effective pain control as a
  fundamental duty
• The literature addressing early pain relief for
  abdominal pain is characterized by weaknesses,
  but there is a common theme suggesting that
  analgesia is safe.

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Thanks for your attention