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PAIN

MANAGEMENT IN
EMERGENCY DEPARTMENT

Dedi Susila, dr., SpAn., KMN., FIPM

Pain and Regional Anasthesia division,
Department of Anastesiology & Reanimasi FK UNAIR-RSUD Dr Soetomo
Introduc)on
Research shows that pain is the primary issue
for more than 70 % of paAents who present at
emergency department ( ED )
60 % to 80 % paAents have acute pain
More than 47 % of the paAents seen in the ED
complain of procedural pains
Most paAents experience pain from
nontraumaAc causes
Michel Galinski, Acute Pain Management in Emergency Medicine
Correspondance: m.galinski@trs.aphp.fr, Site CNRD: www.cnrd.fr
Categories of illnesses presen)ng
with pain in ED
Trauma (fractures, dislocaAons, strains)
Wounds
Back and neck pain
Abdominal pain
Headache
Chest pain (noncardiac)
Abscesses, celuliAs
Toothache
Urinary tract infecAon
Upper respiratory tract infecAon
Renal colic
Todd KH et al. Pain in the emergency department: results of the pain and emergency medicine
iniMaMve (PEMI) mulMcenter study. The Journal of Pain 2007; 6:460-466
Barriers to Pain Management
A recent study shows that pain treatment is
also inadequate in ED world wide
It has recognised the term of oligoanalgesia
Barriers to pain management into :
- Healthcare system related
- Healthcare provider related
- PaAent related
MarMn Duignan, Barriers to Pain Management in Emergency Departments, Emergency
nurse vol 15 no 9 February 2008
ObjecAve of the Pain Management In ED

RecogniAon of pain and measurement of its


intensity
Treatment adapted to the intensity, the
paAent and the pathology
SystemaAc and regular reassessment
permiZng an appreciaAon of the eciency of
the treatment
Take into account procedural pains
Mechanism of Acute Pain in ED
Acute pain in emergency situaAons is mainly
due to excessive nocicepAon which is
secondary to an inammatory reacAon, a
trauma or visceral lesion ( Fletcher 2004 )
However, neuropathic pain was present in
more than 20% of paAents in the ED and
necessitated a specic clinical invesAgaAon

Michel Galinski, Acute Pain Management in Emergency Medicine


Correspondance: m.galinski@trs.aphp.fr, Site CNRD: www.cnrd.fr
Tissue Injury

Cell Membrane Phospholipids

Phospholipase

Arachidonic Acid
COX-1 COX-2

Prostaglandins Prostaglandins
Gastric ProtecAon Acute Pain
Kidney protecAon InammaAon
Platelet Hemostasis Fever
THE BEGINNING OF INFLAMMATION PAIN

Nociceptor
Eec)ve management of acute pain
in the ED requires :
1 Assessment of the pain
2 Provision of appropriate analgesia in an
appropriate Ame frame via an appropriate
route
3 Reassessment of pain to determine the eect
of treatment and assess for adverse eects

Emergency Care Acute Pain Management Manual, Australian Government


NaMonal Healt and Medical Research Council, 2011
Wanne morris et all, EssenMal Pain Management 1 st ediMon 2011
Pain Assessment
Assessment and reassessment of pain should
be made to determine the ongoing eect of
analgesia
Reassessment should also consider the
potenAal adverse eects of analgesia
Measurement pain score
- Self-report measurement ( VAS, NRS, etc )
- Non-self report measurement ( FLACC, BPS )
Assessing the pa)ent with pain
Onset and duraAon
LocaAon / distribuAon
Quality
Intensity
AggravaAng / relieving factors
Associated symptoms
Treatment response
MAKE A PAIN DIAGNOSIS!!!
1. Assessment of severity
2. Is the pain acute or chronic ?
3. Is the pain cancer or non cancer ?

4. Is the pain nocicepAve, neuropathic
or mixed ?

Case example 1:
8 year old boy with probable appendiciAs
waiAng for an operaAon and he fell severe pain
in his abdomen.

DX : - severe pain
- Acute pain, non cancer cause
- NocicepAve mechanism
- Other factors may be contribuAng ( fear,
anxienty )
Case example 2:
55 year old woman with metastaAc breast
cancer. Large tumour of lem breast with spread
to spine causing severe pain.

DX : - Severe pain
- Chronic cancer pain and acute musculoskeletal
pain caused by spinal metastases
- Both nocicepAve and neuropathic mechanism
- MulAple factors maybe contribuAng
Target Point of Analgesic Agents
Ketamin
Paracetamol
Gabapen)n
Percep)on
Opioids
Gabapen)noids
Clonidine
Dexamethasone
Ketorolac
Cor)costeroids
NSAID
Modula)on Transduc)on COXIB
Local Anesthe)c

Transduc)on
DRG

Transmission
Modula)on
Local anesthe)cs
Cryotherapy
COXIBs
Assessment of acute pain in the ED

The College of Emergency Medicine Best PracMce Guideline


Management of Pain in Adults, Desember 2014
Algorithm for treatment of undieren)ated
acute pain in ED

The College of Emergency Medicine Best PracMce Guideline


Management of Pain in Adults, Desember 2014
CEM RecommendaAons
( Updated in December 2014 )
Analgesia for moderate and severe pain
should be given within 20 minutes of arrival in
the ED
The eecAveness of analgesia should be
reevaluated within 30 minutes of receiving the
rst dose of analgesia

It is important that the lack of diagnosis does
not delay administraAon of appropriete
analgesia
RecogniAon and alleviaAon of pain should be a
priority
This process should star at triage, be
monitored during the paAent Ame in the ED
Analgesic Dosage, PrecauAons
and Comorbidity
Titrate opiods to desired eect. Respiratory
depression and hypotension possible side
eects
Use cauAously if hemodynamic instability,
respiratory dysfuncAon, or mulAsystem
trauma
The use of opioids in abdominal pain does not
hinder the diagnosis prosess
Analgesic Dosage, PrecauAons
and Comorbidity.
Extremes of age at risk for inadequate and
pharmacotherapy complicaAons
Elderly at risk for drug-drug interacAons
Drug-disease interacAons
Altered HepaAc and Renal funcAons
PaAents with respiratory insucency and
COPD, cysAc brosis etc

FasAng paAents ( nil by mouth ) may be
administreted oral analgesia unless they have
( or are suspected of having ) one of the
following condiAon :
Bowel obstrucAon
Perforated viscus
Compromised swallow e.g. stroke
Compromised airway

Emergency Care Acute Pain Management Manual, Australian Government


NaMonal Healt and Medical Research Council, 2011
Non-pharmacological analgesic
techniques :
ImmobilisaAon of injured limbs or body parts
Ice and elevaAon
ExplanaAon of cause of pain and likely
outcomes to allay anxienty
Keeping the paAent in as calm an
environments as possible
Psychological techniques such as distracAon

Emergency Care Acute Pain Management Manual, Australian Government


NaMonal Healt and Medical Research Council, 2011
Conclusion
EecAve analgesia in the ED requires
appropriate assessment and re-assessment, use
of the appropriate drug (s) in appropriate doses,
via the appropriate route an acceptable Ame
frame