acut management.pptx

1. REFRAT
MANAGEMENT OF ACUTE
PAIN
Oleh : Fika Anugrah Zulfathon
NIM : H1A014007
Pembimbing : dr. Eliya Sp.AN

2. OUTLINE
• Background
• Definition
• Classification
• Phyisiology
• Pain scoring
• Management of acute pain

3. BACKGROUND
• Acute pain is a sudden onset pain, felt immediately
after injury, severe intensity, usually temporary for
several minutes to several days
• It is usually caused by tissue damage and is
associated with some degree of inflammation that
stimulates the nociceptor and is generally lost
when curing an injury

4. DEFINITION
• Pain is defined by the International Association for the Study
of Pain as an unpleasant sensory and emotional experience,
related to actual or potential tissue damage or is described
in terms of the damage. Classification based onset :
Acute pain :
- Sudden Onset
- Immidietly after injury
- The instensity is severe
- But usually lasts for a while
Chronic pain :
- continuous or recurrent pain
- pain lasting more than three
months

5. CLASSIFICATION
Nosiseptif pain
Somatic pain
Viseral pain
Neurotic pain

6. PHYSIOLOGY
1. Transduksi : Transduction, is the process by
which a stimulus from the origin of the dome
becomes the electrical activity commonly
called the action potential
2. Conduction; is the process of propagation
and amplification of the action potential or
electrical impulse from the nociceptor to the
posterior horn of the spinal cord in the spine
3. Modulation; is the process of inhibition of
electrical impulses entering into the posterior
horn, which occurs spontaneously in varying
strengths of everyone, (influenced by
educational, religious or cultural background).

7. PHYSIOLOGY
4. Transmission; is the process of moving
electrical impulses from the first neuron to the
second neuron occurs in the posterior cord of
the spinal cord, from which it rises through the
spinothalamic tract to the thalamus and
midbrain
5. pain perception is a conscious experience of
the incorporation of sensory activity in the
somatosensory cortex with the emotional
activity of the limbic system, which is finally
perceived as pain

8. PAIN SCORING
Visual analog scale
Numeric rating scale
Faces scale from wong backer

9. 1. VISUAL ANALOGE SCALE
• VAS is the most commonly used scale for assessing pain intensity, sensitive
consisting of a straight line of 0-100 mm, with the words 'painless' on the left end
and the 'worst imaginable pain' on the right

10. 2. NUMERIC RATING SCALE
• Verbal numerical rating scale
(VNRS) is a simple and fast
assessment, and correlates well
with VAS. Consists of a simple 0-10
verbal scale. Patients were asked to
assess the pain verbally on a scale
of 1-10, with 1 very minor
inconvenience and 10 being the
most severe pain imaginable or
experienced.
A Verbal scale rating scale (VNRS) ssessment
using phrases such as "what is your pain?" "Is
it mild, moderate, or severe?" 3 Patients are
asked to report their pain as "none," "mild",
"moderate", "severe" or "very severe "using a
verbal ranking scale or verbal descriptor scale.
The effectiveness of this tool is limited in
multilingual societies

11. FACES SCALE FROM WONG BACKER
• Wong-Baker's FACES® pain rating scale has been validated for children aged ≥ 5
years. It can also be used for adults with cognitive impairment

12. MANAGEMENT OF ACUTE PAIN
• 1. Management Objectives
• a. Early intervention, with rapid
adjustment in regimens for
uncontrolled pain
• b. Pain reduction to an
acceptable level
• c. Facilitate recovery from an
underlying disease or injury
2. Treatment strategy
a. Multimodal analgesia
Use of more than one method or
modalities of pain control
b. Preempatif analgesia
Administering one or more
analgesics prior to the event that
will cause pain (eg surgery) in an
attempt to prevent peripheral and
central sensitization, minimizes
post-injury pain.

13. The WHO analgesic ladder is part of an overall pain treatment method that
centers on five key principles
c. Steps three
• If or when non-opioids for mild to
moderate pain are no longer
enough to relieve pain, switch to
opioids that are not combined
with other agents such as
acetaminophen, and one that is
effective for moderate to severe
pain (eg morphine, oxycodone,
hydromorphone).
• Add or continue adjuvant, if
appropriate "For Individuals":
individualize the Pain
Management Program according
to the patient's intent to include
criteria for the Center of Persons
to meet the patient's pain needs.

14. The WHO analgesic ladder is part of an overall pain treatment method that
centers on five key principles
5 principles :
1. By mouth
2. By the clock
3. By the ledder
a. Step one : For mild to moderate
pain, start with nonopioids (eg,
Acetaminophen, ibuprofen) and
increase the dose, if necessary to
the maximum recommended
dose. • Use adjuvants such as
antidepressants or
anticonvulsants, if indicated • If
the patient presents with
moderate or severe pain, skip
Step 1
b. Step two :
If or when non-opioids do not
adequately relieve pain, add opioids
aimed at moderate pain such as
hydrocodone (combined with
acetaminophen). Add or continue
adjuvant, if appropriate

15. ANALGESIK NON OPIOID
1. Paracetamol
• It has analgesic and antipyretic properties but does not have anti-inflammatory
properties
• Its antipyretic effect through inhibition of prostaglandin synthesis in the central
nervous system, but until now the mechanism of action is not known clearly
• It is the safest non-opioid analgesic
• Dose 500-1000 mg every 4-6 hours, maximum 4g / day. Metabolism occurs mostly
in the liver. Side effects may be hepatotoxic, especially in patients with liver or
malnutrition

16. 2. NSAID
• NSAIDs are widely used to treat mild to moderate pain and also to reduce opioid
consumption in the perioperative period.
• It acts by inhibiting COX-1 and COX-2 enzymes that convert arachidonic acid into
prostaglandins and thromboxane, in which prostaglandins are one of the mediators
of pain and inflammation.
• COX-1 is expressed constitutively for physiological functions such as renal function,
gastric mucosal protection, and platelet function.
• NSAIDs are widely classified according to their particular COX enzyme inhibition.
• Commonly used NSAIDs (eg ibuprofen, diclofenac) are non-specific COX inhibitors
while certain COX-2 inhibitors avoid the side effects of COX-1 inhibition.

17. OPIOID
• Opioids are the strongest analgesics and are very commonly used after surgery,
cancer, burns and more.
• Opioids work by binding to specific receptors (called receptors μ) Activation of μ
receptors will inhibit pain transmission both peripherally and centrally.
• Opioids should be given with a titration dose. The ideal dose is achieved when the
pain is reduced and side effects can be tolerated.
• Dosage should be lower in geriatric patients, renal failure, impaired liver function,
because it tends to have side effects due to opioids.
• Known as two opioids ie weak opioids such as codeine and tramadol, and powerful
opioids, for example morphine, pethidine and fentanyl.

18. WEAK OPIOIDS
• Opioid drugs produce analgesia by reducing neuronal stimulation and inhibition of
neurotransmitter release from the primary afferent terminal in the spinal cord and
the activation of descending inhibitor control in the midbrain.
• Commonly used weak opioids are codeine and tramadol, which are used in
conjunction with the WHO 1 step drug in step

19. POWERFULL OPIOID
• Strong opioids are present in the third step in the WHO analgesic staircase for
severe pain.
• Morphine is considered the gold standard of opioid analgesics. Other powerful
opioids commonly used in perioperative settings include oxycodone, diamorphine,
fentanyl, and alfentanil. strong opioids are given orally or parenterally as an
intermittent bolus or continuous infusion.
• All opioids have similar side effects such as sedation, nausea and vomiting,
constipation, common itching and more serious side effects of respiratory
depression. It is important to provide supplemental oxygen and often monitor vital
signs, particularly respiratory rate and oxygen saturation (SpO2) for patients with
strong opioid infusions or patient-controlled analgesia (PCA) systems.

20. CONCLUSION
• Pain is a multidimensional phenomenon with sensory, physiological, cognitive,
affective, behavioral and spiritual components. Based on its etiology, pain is
classified into nociceptive pain and neuropathic pain. In addition, based on their
intensity and periodicity, pain is differentiated into acute and chronic pain. Acute
pain service is a treatment that aims to provide optimal pain relief to all patients
with acute pain with minimal side effects.

21. REFFERENCE
1. World health organization. Guidelines on the pharmacological treatment of persisting
pain in children with medical illnesses. 2012.
2 . Team APAO. Acute Pain Guidelines. North Devon Healthcare: Raleigh Park, 2017.
3. Ministry of health Republic of Rwanda. Pain management guidelines. 2012.
4. Jones M. Management of acute pain. Surgery 2016; : 1–7.
5. Anaesthesiologists TSAS of. Acute Pain Guidelines. Prof Nurs Today 2017; 21.
6. Committee BP. Pain Management Guideline. Heal Care Assoc New Jersey 2006; : 1–30.
7. Tanra AH. Nyeri akut. PT GAKKEN: Makassar, 2017.
8 . American Society of Anesthesiologists. Practice Guidelines for Acute Pain Management
in the. Anesthesiology 2012; 116: 248–273.
9. Mahmud. Strategi Layanan Nyeri Akut Center di DIY. J Komplikasi Anestesi 2014; 1: 45–
49.
10. Bloor A, Somerset J, Mustard L. Management of Severe Pain - General Guidelines and
Essential Information. Mid Essex Hosp Serv 2017.