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.
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.
Clinical examination
ESTABLISHING A PAIN MANAGEMENT PROCESS IN THE EMERGENCY DEPARTMENT
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:
ASSESSMENT OF PAIN
Analgesia is most effective when the patient’s medications are tailored to their requirements.
Adequate pain assessment begins with the history and physical examination.
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.
Pain score | Suggested analgesic |
---|---|
1–2 | Paracetamol PO ii tabs |
3–4 | Paracetamol and codeine 8 mg PO ii tabs |
5–7 |
THE RATIONAL USE OF ANALGESICS AND SEDATIVES
Always refer to the drug’s product information (PI) before prescribing or administration.
Guiding principles
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.