Pain management in the emergency department

Published on 14/03/2015 by admin

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Chapter 13 Pain management in the emergency department

Emergency physicians should be competent in the management of pain. The early relief of pain is a right and an expectation when a patient presents to the emergency department. The management of pain is often compromised by misunderstandings, myths, prejudice and inappropriate reliance on inflexible cookbook formulas. Good patient care demands effective pain relief; failure to effectively manage pain is a failure in the quality of care.

Many patients presenting to the emergency department in pain, including those transported by ambulance, remain in pain for prolonged periods after arrival.

Time-to-analgesia (from arrival/triage time) is one of the areas of current focus in the improvement of the quality of care in emergency departments. Studies have demonstrated that delayed and sub-therapeutic pain relief remains a problem, with a median of 58 minutes or more (up to 107 minutes for less urgent triage categories) for time-to-analgesia.

A range of strategies, including nurse-initiated analgesia, have been implemented in order to achieve the time-to-analgesia benchmark of 20 minutes.

Time-to-analgesia will be influenced by many factors, including the patient’s triage category. Patients in severe pain should be allocated triage category 2 (to be seen by a doctor within 10 minutes of arrival) in order to ensure analgesia is administered early. Alternatively, where nurse-initiated analgesia is available, patients in pain may be allocated lower triage categories, unless their condition requires otherwise.

THE APPROACH TO PAIN MANAGEMENT

Acute pain is a symptom, not a diagnosis.

While it is important to treat the pain, the cause should always be identified and treated.

Frequently the cause is obvious, such as acute appendicitis or trauma. Many times, however, the exact underlying aetiology is not clear and a diagnostic work-up is required. A history from the patient or a parent is essential to determine aetiology. The history and examination should cover the following items.

History

• History of present illness (HPI)

• Current medications

• Medication allergies

• Past medical history

• Social history

• Family history

Clinical examination

• Observation of response to pain (particularly pre-verbal or cognitively impaired patients), e.g. rubbing a particular area, guarding, facial expression, vital signs (tachycardia, hypertension, tachypnoea).

• Focused physical examination (part of body or region in pain), to include vital signs. Increases in pulse, respiratory rate and blood pressure are often but not always noted in the presence of acute pain. However, vital signs may be normal as a result of other physiologic factors.

• Functional assessment.

Note: Pain medications should not be withheld during initial evaluation for an acute abdomen or any other acute painful condition.

Further diagnostic work-up

Pathology studies, X-rays or other diagnostic tests may be needed, directed by the findings of the history and physical examination.

Specialty consultation

Specialty consultation may be required, particularly for patients with chronic pain syndromes.

ESTABLISHING A PAIN MANAGEMENT PROCESS IN THE EMERGENCY DEPARTMENT

Up to 70% of patients presenting to the emergency department have pain as part of their presenting complaint.

It is important to ensure that there is an efficient and effective process of patient care in the emergency department that includes a sub-process focusing on pain management.

In order to ensure rapid and adequate analgesia for patients presenting with pain, a process of pain assessment and management needs to be in place.

Key components of this process are:

• an alerting/activation process (commonly performed by the triage nurse)

• a uniform method of assessment utilising a standardised pain scoring system

• commonly performed by the triage nurse

• use of a nurse-initiated medication policy can minimise delays in administering analgesia.

The triage process and triage form (electronic and/or hard copy) should incorporate assessment of pain and allocation of a pain score in addition to prescribing and administering analgesia (and other essential medications), with provision for monitoring vital signs including the pain score and response to treatment.

1. Use of a pain pathway or guideline (can be incorporated into a specific condition guideline/pathway)

2. Documentation

3. Ready access to the required equipment and medications

4. Ongoing monitoring of the patient including their response to analgesia (including use of a pain score and, where indicated, a sedation score)

5. Quality of care monitoring using quality indicators such as time-to-analgesia (from time of triage to time of administration)

ASSESSMENT OF PAIN

The assessment of pain with the allocation of a pain score should be considered as one of the seven vital signs.

Accurate assessment of severity and character of the pain and the individual’s response to it is essential in order to decide on the pain management required.

Analgesia is most effective when the patient’s medications are tailored to their requirements.

Different levels of distress from similar degrees of pain stem from variations in a range of factors including culture, ethnicity, environment, beliefs, perceptions of pain, religious beliefs, age, illness, duration of pain and associated symptoms.

Adequate pain assessment begins with the history and physical examination.

There are a range of factors that should be used in assessing the severity of pain and the response to treatment. These include:

• physiological factors

• blood pressure

• respiratory rate

• behavioural features

• pain scales.

A visual analogue scale (VAS) in centimetres may be used to evaluate the patient’s subjective sensation of pain (Figure 13.1).

Alternatively, a numerical rating scale (NRS) from 0 to 10 (0 = no pain, 10 = worst possible pain, see Table 13.1) has been demonstrated to correlate closely with the VAS in measuring pain, with the VAS and the NRS having almost identical minimum clinically significant differences.

Table 13.1 Suggested analgesia for acute pain in adults based on the VAS or NRS

Pain score	Suggested analgesic
1–2	Paracetamol PO ii tabs
3–4	Paracetamol and codeine 8 mg PO ii tabs
5–7	Paracetamol and codeine 30 mg PO ii tabs or Tramadol 50–100 mg IVI

8–10 Morphine IVI

Pain response is unique to each individual. A good guide to adequate analgesia is the dozing patient who opens the eyes when his or her name is called.

In the evaluation of acute pain, a difference in the VAS of < 20 mm is unlikely to be clinically significant.

Ongoing monitoring and assessment of pain severity should take place every 2 hours (more frequently where pain is a major feature of the patient’s condition), in addition to requests from the patient for analgesia, and every 8 hours once the pain is controlled.

It is useful to determine the type of pain the patient is experiencing as this can guide the selection of analgesics (more than one type of pain may be present). Pain may be one of three types: somatic, visceral or neuropathic.

1. Somatic pain is well-localised and may be responsive to paracetamol, cold packs, corticosteroids, localised anaesthetic (topical or infiltrate), non-steroidal anti-inflammatory drugs (NSAIDs), opioids and tactile stimulation.

2. Visceral pain is more generalised and is most responsive to opioid treatment.

3. Neuropathic pain may be resistant to opioid therapy and consideration should be given to adjuvant therapy such as tricyclic antidepressants and anticonvulsants.

Table 13.2 Tool for determining type of pain

THE RATIONAL USE OF ANALGESICS AND SEDATIVES

A large number of pharmacological agents exist, each with their own indications, contraindications, modes of action and routes of administration. In order to select the correct agent, an understanding of the principles that determine the use of analgesics and sedatives in the emergency department is required.

Always refer to the drug’s product information (PI) before prescribing or administration.

Guiding principles

• Rapid onset of action is required.

• Agents need to be effective, i.e. potent.

• Judicious intravenous administration, either bolus or by an infusion (titration to effect desired), is the most effective way to achieve the desired result.

• Duration of effect is important.

• Concurrent administration of a sedative enhances patient comfort and cooperation.

• A good understanding of the agent’s adverse effects is essential for safe use.

• Resuscitation skills, including airway management, together with a full range of resuscitation equipment, are essential to deal with the occasional situation that occurs as a result of excessive sedation or an allergic reaction.

• Administration of oxygen via mask or nasal cannula with monitoring by oximetry should be considered. (Capnography should also be considered and should be used where there is a risk of hypoventilation leading to hypercapnia.) Patients with known respiratory and cardiovascular disease should be given supplemental oxygen and their oxygen saturation should be monitored; cardiac monitoring may also be necessary.

Pharmacological agents

Simple analgesics

Acetylsalicylic acid (aspirin) with or without codeine, and paracetamol with or without codeine, are commonly used for mild pain. Both are also used as antipyretics; aspirin also has an anti-inflammatory action. Non-steroidal anti-inflammatory drugs (NSAIDs) are also commonly used as analgesics. NSAIDs are more potent analgesics than paracetamol and aspirin. Table 13.3 lists the commonly used agents and their properties.

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