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Preface

Pain and Sedation Management In the21

Century Emergency Department

Guest Editors

Pain is the most common reason patients seek care in emergencydepartments (ED), with as much as 70% of patients having pain as part of their presenting complaint. Emergency physicians treat many patients withmany etiologies and levels of pain. The volume and severity of pain-relatedproblems make pain management a core skill in emergency medicine, yetthere is ongoing evidence that pain is inadequately treated in the ED. Formore than a decade we have identiﬁed that pain is undertreated inemergency medicine. Wilson coined the term ‘‘oligoanalgesia’’ in 1989 forinadequate use of methods to relieve pain.So, how then do we (emergency care providers) improve on our painmanagement? First, fundamental changes in the attitudes of emergencyproviders regarding pain assessment and pain management are necessary toprevent such ‘‘oligoanalgesia’’ in the emergency environment. This changein attitude requires that providers recognize and treat pain as a trueemergency. Changing the attitudes of emergency medical providers aboutpain assessment and management will require attention in several areas of research, education, and training. Next, a better understanding of thepathophysiology, measurement, and optimal therapies for pain must belearned and taught to all our providers. Also, patient needs and expectationsfor pain relief, as well as continued eﬀorts at patient education regardingpain, will also improve our treatment of pain in the ED. Finally, providersmust understand various future aspects of education, evaluation, andtherapy that may allow us to optimize pain care.

John G. McManus, Jr, MD, FACEP Benjamin Harrison, MD, FACEP0733-8627/05/$ - see front matter

emed.theclinics.com

Emerg Med Clin N Am 23 (2005) xv–xvi

The last 15 years have seen a substantial increase in ED research focusedon pain and pain management. Continued research efforts and focusedclinical application of these efforts are still required. Recognition byproviders of the ethnic, cultural, and gender differences in the expression,reporting, and expectations for treatment of pain should also continue to bea priority in changing attitudes toward pain and pain control. These goalsmust be realistic within the chaotic and unpredictable environment thatdefines emergency medicine. Practical and time-sensitive approaches to painand pain management will continue to be a challenge to enact and enforce inour EDs.The consequences of ‘‘oligoanalgesia’’ in the ED are not insignificant. Toimprove our treatment of pain in the ED, a fundamental change in attitudetoward pain and the control of pain is required. This is unlikely to occuruntil pain is adequately addressed and treated appropriately as a trueemergency. This edition of

Emergency Medicine Clinics of North America

hopes to reinforce the importance of pain education, management, andtreatment for our emergency medical patients.John G. McManus, Jr, MD, FACEP

The Army Institute of Surgical ResearchBrooke Army Medical CenterSan Antonio, TX 78258, USA

Benjamin Harrison, MD, FACEP

Department of Emergency MedicineMadigan Army Medical CenterTacoma, WA 98431, USA

xvi

PREFACE

The Pathophysiology of Acute Pain

Walter Allen Fink Jr, DO, FAAEM, FACEP

United States Army, Major, Department of Emergency Medicine, Madigan Army Medical Center-University of Washington, Tacoma, WA 98431, USA

The sensation of pain is a neural-biochemical phenomenon. When acutetissue damage occurs, neurochemical reactions at the site of injury activatethe free nerve endings of special nerves called nociceptors. Nociceptorsinitiate an afferent nerve impulse that propagates through the peripheralnerve, enters the spinal cord, and synapses with higher order neurons. Theimpulse then traverses specific ascending spinal tracts, landing in cerebralcenters for interpretation. Modulation of the afferent information can occurin many areas, including the periphery, spinal cord, midbrain, and cerebralcortex. Interpretation of the impulse yields a response signal, again travelingthrough specific descending spinal tracks and out through peripheral motornerves. This process partially accounts for the delay in feeling a sensation of pain after experiencing an acute injury. Pain sensations can be categorized inmany ways, based upon their speed in traveling in the nervous system (fastand slow pain), the length of time the pain has continued (acute or chronicpain), or the anatomical etiology of the sensations (somatic or visceral pain).This article discusses the anatomy and physiology of pain sensations,concentrating on acute pain mechanisms. Limited discussion is offeredregarding the modulation of pain sensations, and there is a brief overview of visceral pain. Discussion of chronic pain pathophysiology is included in thearticle by Hansen on chronic pain elsewhere in this issue.

Pain receptors and peripheral nerve ﬁbers

Nociceptors transduce noxious stimuli into a nerve impulse, and thefeeling of physical pain is initiated with its activation. The cell bodies of nociceptors are located in the dorsal root ganglion of the spinal nerve ateach level, or the trigeminal ganglion for the trigeminal nerve. This is typicalfor all peripheral nerves. Each cell body possesses two branches, one

E-mail address:

Walter.fink@nw.amedd.army.mil0733-8627/05/$ - see front matter

emed.theclinics.com

Emerg Med Clin N Am 23 (2005) 277–284