PRESENTER: DR ABDUL MUHAIMIN BIN MAT

SULAIMAN
SUPERVISOR: DR SOLEHIN
“Tidaklah seorang muslim ditimpakan kepayahan,
penyakit, kegoncangan, kedukaan, maupun kesulitan,
bahkan sampai duri yang menusuknya, melainkan
dengannya Allah akan menghapuskan kesalahan-
kesalahannya.”
( Mutatafaq’alaih)
“Those who do not feel pain
seldom think that it is felt.”

Dr. Samuel Johnson

(1709-1784)
 Definition of Pain

“An unpleasant sensory and emotional

experience associated with actual and
potential tissue damage or described in terms
of such damage”

IASP Subcommitee on Taxonomy.

Pain 1980; 8:249-252
 Definition of Pain

Pain is when the patient says - hurts

• Pain – a common symptom, very individualized and
very subjective
 Issues
• Pain is the most common reason patients present to
Emergency and Trauma Department (ETD)

• Difference in perception of Pain among Patients and

Physician

• Pain as 5th VS

• Timelines in Pain management

Timelines in Pain management
Holistic Pain Management

• Primary Triage
• Secondary Triage
• Surveillance Triage
AVAILABLE PAIN ASSESSMENT TOOLS :
• Numerical Rating Score (NRS)
• Visual Analogue Score (VAS)
• Combination Rating scale
(NRS &VAS)
• Categorical Score
• Functional Score
• FLACC Observational Pain Score
• Wong Baker Faces Scale
 i. Numerical Rating Scale (NRS)

“ If ‘0’ = no pain, and ‘10’= the worst

pain you can imagine, what number is
your pain now?”
 ii. Visual Analogue Score
▪ Patient is asked to slide a small bead along
a scale to indicate the severity of pain
▪ Total length of scale is 100 mm (10 cm)
 iii. Combination Rating Scale (NRS & VAS)

“On a scale of ‘0’ – ‘I0’ (show the pain scale), if

‘0’ = no pain and ‘10’ = worst pain you can imagine,
what is your pain score now?”
•Patient is asked to slide the indicator along the scale to show
the severity of his/her pain
•Nurse records the number on the scale (zero to 10)
 iv. Categorical Scale
Patient rates pain using words : mild, moderate,
severe pain
0 = No pain
1 = Slight / mild pain
2 = Moderate pain (tolerable)
3 = Severe pain
4 = Worst pain imaginable
(intolerable)
- Not a preferred method (not sensitive)
 v. Functional Score
Functional limitation :
Ask patient :
‘ Can you sit up?’
‘ Can you take deep breaths?’
‘ Can you walk this morning?’

-Not a preferred method

-Nurse is not able to record the numeric score
for the level of pain, only able to know the
functional level
vi. FLACC Score
(By Observation)
 For Paediatric < 4 yrs
 elderly patient
 cognitively impaired patient

I. Observe behaviour
II. Select score according to behaviour
III. Add the scores for the total
vi. FLACC SCORE
vii. Wong-Baker Faces Pain Rating Scale
 WHICH TOOL TO USE
• Use the standard tool for pain assessment as
recommended by Ministry of Health, Malaysia
– For adult patients, use the combined NRS / VAS
scale
– For paediatric patients 1 month to 3 years old, use
the FLACC
– For paediatric patients > 3-7 years, use the Wong-
Baker FACES scale
– For paediatric patients >7 years, use the combined
NRS/VAS scale (same as for adults)
*Always use the same tool for each patient
 Analgesics
↙ ↘
↙ ↘
Non Opioids
– Paracetamol Opioids
– NSAIDS Weak
– COX 2 inhibitors
Strong

26
 DRUG
Formulations AndFORMULATION AVAILABLE
Paracetamol
NSAID
Diclofenac
Mefenamic Acid (Ponstan)
Ibuprofen ( Brufen)
Naproxen (Naprosyn, Synflex)
Ketoprofen (Orudis, Oruvail)
Ketorolac (Toradol)
Meloxicam ( Mobic)
Dosage Of Commonly
Used Analgesics
Tablet 500mg,
Suspension 500mg/5ml,
Suppositories
Tablet 50mg & 25mg,
Suppositories 12.5mg, 25mg,
(50mg & 100mg)*
Gel
Capsule 250mg
Tablet 200mg & 400mg*
Tablet 250mg, 550mg
Capsule 100mg *, Injection
100mg,
Patch 30mg, Gel
Injection 30mg/ml
Tab 7.5mg
DOSAGE
500 mg – 1gm qid
Oral: 50mg tds,
Sup: 50mg-100mg stat
Topical: PRN
250 mg – 500mg tds
200 mg – 400 mg tds
500mg-550 mg bd
Oral: 100mg daily, IV: 100mg bd
Patch: 30mg - 60mg bd, Topical:
PRN
10mg - 20 mg bd max 3 days
Daily or bd
 DRUG FORMULATION AVAILABLE DOSAGE

COX 2 inhibitors
Celecoxib Capsule 200 mg 200 mg bd (max 1 week)
Etoricoxib Tablet 90 mg & 120 mg 120 mg daily (max 1 week)
Parecoxib Injection 20 mg/ml 40 mg bd ( 20 mg bd for elderly) max for 2
days
WEAK OPIOID

Tramadol Capsule 50mg, Injection 50mg -100mg tds or qid (max 400mg/day)
50mg/ml
Dihydrocodeine Tablet 30 mg 30mg-60mg qid (max 360mg/day)
(DF118)
 DRUG FORMULATION DOSAGE
AVAILABLE

STRONG OPIOID

Nalbuphine Injection 10mg/ml Stat dose only: 10mg (equivalent to Morphine

(Nubain) 10mg). Do not use in patients on regular
Morphine/ Pethidine/ Fentanyl.
Morphine Tablet SR 10mg,30mg SR and Aqueous to be used for cancer pain
Aqueous 10mg / 5ml IV and Subcut :
Injection 10 mg/ml, < 65yrs : 5mg -10mg 3-4hrly
> 65yrs : 2.5mg -5mg 3-4hrly
Reduce dose in renal and hepatic impairment
Fentanyl Injection 50 mcg/ml, IV only to be prescribed by APS team.
Patch 25 mcg, 50 mcg Patch to be used in cancer pain; NOT in Acute
Pain
Pethidine Injection IV and Subcut :
50mg/ml,100mg/2ml < 65yrs : 50mg -100mg 3-4hrly
> 65yrs : 25mg -50mg 3-4hrly
Reduce dose in renal and hepatic impairment.
Use not encouraged because of Norpethidine
toxicity and high risk of addiction.
Oxycodone Tablet SR 10mg & Mainly used for cancer pain
(Oxycontin) 20mg
 Analgesic Ladder for
Acute Pain Management SEVERE UNCONTROLLED

7-10
To refer to APS for:
Regular PRN PCA or Epidural or
MODERATE Higher dose of IV/SC other form of
weak opioid Morphine analgesia
Or 5-10mg
4-6 IV/SC OR
Morphine 5- Aqueous
10mg 4 hrly morphine
Regular PRN
MILD OR *Oral or SC
Weak Opioid Additional
Aqueous Morphine may
± PCM 1gm weak
morphine 10- be safely given
QID oral opioid
0-3 20 mg at hourly
± NSAID /
± PCM 1gm intervals
COX2 inhibitor
QID oral /
Regular PRN rectal
No PCM &/or ± NSAID /
medication NSAID / COX2 inhibitor
or PCM COX2
1gm 6hrly inhibitor
 Morphine Pain Protocol
• Used for rapid control of severe pain
• Route: IV
• Morphine dilution: 10 mg in 10 mls (1mg/ml)
• Monitoring (every 5 minutes)
– Pain score
– Sedation score
– Respiratory rate
– Pulse rate
– Blood pressure
Morphine
Pain Protocol
Adapted from the
Acute Pain Service,
Royal Adelaide
Hospital , South
Australia
 SEDATION SCORE

0 = None, i.e patient is awake and alert.

1 = Mild, i.e occasionally drowsy, but easy to
rouse.
2 = Moderate, i.e frequently drowsy, but still
easy to rouse.
3 = Severe, i.e difficult to rouse.
S = Sleeping, i.e asleep, responds to call / touch
 SEDATION SCORE
• Sedation score is a more sensitive assessment
for respiratory depression and
hypoventilation.
• Patient is usually noted to be heavily sedated
before they developed hypoventilation.
• Therefore, a sedation score > 2 should alert
the health care provider of oncoming danger.
PROCEDURAL SEDATION AND ANALGESIA

• To induce depressed level of consciousness

• Maintaining cardiorespiratory function

• To perform procedure / reduce reaction / memory

PROCEDURAL SEDATION AND ANALGESIA

• GOAL
POINT TO NOTE
 Unpredictable

 Time dependent / emergent

 Gastric – no need fasting

 Pre procedural pain – moderate to severe

 Patient not selected

STEPS
1. Before procedure
2. During procedure
3. After procedure
Before Procedure

Prepare -

• Assess pt’s condition and VS

• Explanation to patient and relative
• Analgesic and sedation
• Instruments
• Prepare ourselves
During Procedure
• Use agreed-upon distraction/coping techniques

• Continuous assessment of vital signs and depth of

sedation
Post-Procedure
• Continue observation, VS monitoring

• Documentation, PSA form

• Aspect pain post procedure

• Referral letter to the respective department/nearest

clinic