Pain Mangement in Emergency

1. Emergency andTrauma Department
IIUM Medical Centre

2.  Pain is the most common complaint to
Emergency Department (ED)  78% visits
 All patients have a RIGHT to pain relief,
creating a duty of care
 Royal College of Surgeons and Anaesthetists
(1990)
 As a 5th vital sign

3.  Analgesia should comprehensive patient
evaluation and management plan
 Emotional and cognitive aspects of pain
 No reliable way to measure pain
 Pain is most often under-treated, not over-
treated
 Pain control must be individualized

4.  Anticipate rather than react to pain
 Let the patient control his or her own pain
 Pain control  best by combination therapy
 Pain control requires a multidisciplinary team

5.  Patient and non patient management
 Pharmacological
 Non pharmacological
 Psychological counseling
 Reassurance / consolation
 Personal interaction
 Ambient / pain relieving environment

6.  The implementation strategies for pain
management as 5th vital sign in EMTS
 Different phases and setting of EMTS
 The team work of pain management
 Total quality management

13.  Guidelines for pain management in
Emergency &Trauma Department

15.  NSAID + colchicine are effective first line analgesic for
acute gout attack
 Technique:
 NSAID
 If contraindicated or ineffective  Colchicine 1000 mg
orally, then 500 mg 1 hour later (maximum 1500 mg per
course) ideally within 12 hours of acute episode
 Consider use of prednisolone when NSAIDs and colchicine
are contraindicated or ineffective
 Prednisolone 50mg orally daily (for 5 days then review)
 Disposition: Pain free discharge and referral to KK/primary
for long term

16.  Antivirals  within 72 hours of onset of the
rash reduces duration of pain, rash and
reduces ophthalmic complications.
 Herpes Zoster therapy and associated pain
management  decreases the risk of Post
Herpetic Neuralgia

17.  If within 72 hours
 Acyclovir 20mg/kg (up to 800mg) orally 5x/day for
7days
 Analgesic technique
 PCM 1g orally QID/PRN and/or OralTramadol +
NSAIDs
 Disposition
 Medical/Dermatology  for definitive management
 Consider pain specialist to prevent chronic pain
 Pain free discharge

18. 1. Pain has at least 2 of
the following features
(PUMA)
 pulsatile
 unilateral
 moderate to severe
 aggravated by
movement
2.There is at least 1 of the
following associated
symptoms:
 nausea
 vomiting
 photophobia
 phonophobia

19.  The headache last between 4 to 72hrs
 No evidence of any other disease that cause
the symptoms

20.  At least three of the following symptoms occur:
 one or more completely reversible aura symptoms.
 aura symptoms include: alterations in vision; numbness or
tingling in the face, arm,
 or hand on one side of the body; muscular weakness or
mild paralysis on one side of the body; and/or difficulty
speaking or loss of speech
 at least one aura symptom develops gradually over > 4
minutes
 two or more symptoms that occur at the same time
 no aura symptom lasts > 1 hour
 headache follows aura within 1 hour

21.  Sudden onset  associated with confusion,
drowsiness, vomiting or neurological signs (e.g.
consider subarachnoid, intracerebral
haemorrhage, dissection)
 Recent onset with fever, confusion or drowsiness
(e.g. consider meningitis, encephalitis)
 Age > 50 years (increased rate of tumours,
temporal arteritis, glaucoma, subdural
haemorrhage and herpes zoster)
 Trauma.

22.  Analgesia technique
 PCM and/or NSAIDs and/or Metoclopramide
 Disposition
 Pain free discharge
 Refer Neuromedical

23.  Analgesia technique
 PCM and/or NSAID

24.  Keypoints
 Analgesia  not hinder the diagnostic
 Non-selective NSAIDs and opioids provide
effective analgesia for renal colic.
 The use of pethidine should be avoided in
favour of other opioids.

25.  Analgesia technique
 For severe pain use:
▪ IV Morphine Pain Protocol
▪ If morphine is contraindicated, consider
▪ Fentanyl at 25 to 50 micrograms IV as initial equivalent dose
▪ NSAID or COX-2 inhibitor
 For moderate pain use:
▪ Tramadol
▪ with or without
▪ NSAID or COX-2 inhibitor

26.  Key points:
 Regular paracetamol, and then if ineffective,
NSAIDS may be used for musculoskeletal pain.
 NSAIDs  used short term.
 Short term oral weak opioids may be required.

27.  Severe pain
 IV Morphine Protocol + IV PCM 1g
 Or oral 4hrly PRN
 And/or
 NSAIDs or COX2 inhibitor
 Moderate
 Oral PCM 4hrly PRN and/or NSAIDs or COX2
inhibitor

28.  Keypoints
 Analgesia NOT hinder diagnostic process
 Analgesia techniques
 For severe pain use:
▪ IV Morphine Pain Protocol
▪ Fentanyl at 25 to 50 micrograms IV
 And
▪ Paracetamol 1g IV (if available) 4 hourly prn (to a
maximum dose of 4g per 24 hour period)

29.  For moderate pain
 Paracetamol 1g orally 4 hourly PRN
 If the oral and rectal routes are contraindicated,
 Tramadol IV/SC 50-100mg 6-8 hourly PRN (to a
maximum dose of 400mg per 24 hour period)
 Disposition:
 Consider referral to Gastroenterologist/ General
Surgeon if recurrent episodes of acute dyspepsia
as outpatient.
 Pain free discharge

30.  Key points
 Simple analgesics and physiotherapy referral  if
from musculoskeletal origin.
 Postural advice, minimizing bed rest, staying
active and heat wrap therapy
 Spinal pathology  osteoarthritis, spondylosis,
bulging discs and canal stenosis are often
asymptomatic and may not be the cause of the
pain.

31.  Symptoms or signs of infection or risk factors for
infection (fever, immunosuppression, steroid use
and history of IV drug use)
 History of trauma (this includes minor trauma in
the elderly, osteoporotic or those on
corticosteroids)
 History of malignancy or recent unexplained
weight loss
 Neurological signs
 Age greater than 50 years.

32.  For severe pain use:
 IV Morphine Pain
Protocol
 and
 Paracetamol 1g orally 4
hourly PRN
 and/or
 NSAIDs or COX-2
inhibitor
 For moderate pain use:
 Paracetamol 1g orally 4
hourly PRN
 and/or
 NSAIDs or COX-2
inhibitor

33.  Key points:
 Titrated boluses of IV morphine  most effective
 Opioid dose requirements will typically be higher
for burns patients
 Non-pharmacological interventions  cooling
and covering

34.  For severe pain use:
 IV Morphine Pain Protocol
 If morphine is
contraindicated, consider
 Fentanyl at 25 to 50
micrograms IV as initial
equivalent dose.
 And
 Paracetamol 1g IV (if
available)/ Oral 4 hourly
PRN
 For moderate pain use:
 Paracetamol 1g orally 4
hourly PRN
 If the oral and rectal
routes are
contraindicated,
 Paracetamol can be given
IV 1g 6 hourly

35.  Key points:
 Evidence for dental pain management  based
on tooth extraction research
 Paracetamol, NSAIDs and tramadol provide
effective analgesia for acute dental pain.
 Dental nerve block  effective analgesia

36.  For severe pain use:
 IV Morphine Pain
Protocol
 If morphine is
contraindicated,
consider
 Fentanyl at 25 to 50
micrograms IV as initial
equivalent dose.
 and/or
 NSAIDs or COX-2
inhibitor
 For moderate pain use:
 Paracetamol 1g orally 4
hourly prn (to a
maximum dose of 4g per
24 hour period)
 or
 NSAIDs or COX-2
inhibitor

37.  Key points
 Immobilisation, resting, the injured site, ice and
elevation
 Femoral nerve block in combination with IV
opioids is more effective than IV opioids alone in
treating pain from fractured neck of femur.
 Anticipate procedures where movement required

38.  For severe pain use:
 IV Morphine Pain Protocol
 If morphine is
contraindicated,
consider
 Fentanyl at 25 to 50
micrograms IV as initial
equivalent dose.
 And/ Or
 Paracetamol can be given
IV/ Oral 1g 6 hourly
 And/ Or
 NSAIDs or COX-2
 For moderate pain use:
 Paracetamol 1g orally 4
hourly prn (to a maximum
dose of 4g per 24 hour
period)
 And/ Or
 NSAIDs or COX-2 inhibitor
 If the oral and rectal
routes are
contraindicated,
 Paracetamol can be given
IV 1g 6 hourly

39.  Key Points
 In suspected ruptured AAA, the most important
 the effect of analgesic to haemodynamic status
 Opioid  titrated doses (recommended)

40.  Severe Pain
 Fentanyl (initial dose 50 to 100 mcg IV, then
titrated)
 Or
 IV Morphine Pain Protocol
 Disposition:
 Refer toVascular/ General Surgeon

41.  Key Points:
 There are no significant differences between
morphine and other pure mu receptor agonists.
 NSAIDs provide good analgesic effect

42.  Severe Pain:
 IV Morphine Pain Protocol (Refer Pain AsThe Fifth
Vital Sign Guidelines Handbook Page 38)
 Or
 NSAIDs or COX-2 inhibitor
 Disposition:
 Consider referral to General Surgeon
 Pain free discharge*

43.  Key Points:
 Marine envenomation can result from discharging nematocysts
(e.g. jellyfish, fire coral), puncturing spines (e.g. sea urchins,
stingrays), or actual bites (e.g. blue octopus, sea snakes).
 For the jellyfish (Cnidaria or Coelenterates) envenomation, hot
water immersion (40 to 45 degree Celsius via immersion or
shower, for up to 90 minutes), can inactivate venom and
achieve better pain relief than alternative approaches such as
acetic acid, papain and opioids).
 Whether considering physical interventions (e.g. warm water
immersion), topical therapies (e.g. acetic acid dousing), or IV
drug therapy (e.g. with antivenom), treatment for different
marine envenomation, even though from different members of
the same genus, can vary significantly.

44.  Warm water immersion or shower (40 to 45
degreeCelsius, as tolerated for 90 minutes)
 Jellyfish: Acetic acid dousing with 4-5% solution
household vinegar
 And/ Or
 IV Morphine Pain Protocol

46.  Guidelines for pain management in
Emergency &Trauma Department