Conclusions: 74% of patients discharge home with moderate to severe pain --> with or without treatment before ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED

1. Acute Pain
Pain Management in Emergency
Ike Sri Redjeki
RSHS/FKUP
Bandung - Indonesia

2. • 80 - 96% in emergency patients  Pain is the single
most common presenting symptom
• 60% of patients in pain had analgesics given with a
median wait time of 90 minutes
• 42% patients were not given analgesics  would have
like to have been given analgesic
• 74% of patients discharge home with moderate to
severe pain
Epidemiology of Pain in Emergency Settings
Todd, K., et al. Pain in the emergency department: results of the pain and emergency
medicine initiative (PEMI) multicenter study. The Journal of Pain 2007; 8: 460-466

3. • 450 trauma patients - pain was measured on admission
• Prevalence admission- 91%
• Discharge (86%) – 2/3 moderate or severe pain at
discharge
• Pain decreased in 37% of the patients, did not change at
all in 46%, or had increased in 17% of the patients at
discharge from the ED
Berben et. Al. Pain prevalence and pain relief in trauma patients in the Accident & Emergency
department . Injury (2008).; May;39(5):578-85
Prevalence of Pain in Trauma Patients

4. Causes of poor management of painful conditions
in the Emergency Department
• Failure to acknowledge pain
• Failure to assess initial pain
• Failure to have pain management guidelines
in ED
• Failure to document pain and to assess
treatment adequacy
• Failure to meet patient’s expectations
Sergey M Motov2, Abu NGA Khan. Problems and barriers of pain management in the emergency
department: Are we ever going to get better? Journal of Pain Research 2009:2 5–11.

5. • Fear of masking injuries and diagnosis
• Fear of impacting hemodynamic status
• Fear of respiratory compromise
• Lower priority
• Underuse of effective analgesic techniques
• Lack of pain protocols/order sets
• Lack of pain management knowledge by providers
 Values and beliefs  !!!!!
Barriers to Pain Management in Emergency Dept

6. Opiophobia
• Opiophobia is the prejudice against the use and prescription
of opioid analgesics
• The result of this is that patients do not receive proper
analgesics, or receive inadequate dosages
• Some ED physicians have significant opiophobia, caused by
lack of proper knowledge about opioid analgesics
• Emergency physicians fear that opioid analgesics will produce
uncontrollable complications, obscure important findings
and impede their ability to secure a diagnosis

7. Assessing the patient with pain
• Onset and duration
• Location /distribution
• Quality
• Intensity
• Aggravating/relieving factors
• Associated symptoms
• Treatment response

8. Pain assessment tools
• Numerical rating scale NRS (0,10)
• Visual analog scale VAS (0,100 mm)
• Faces scale:
• Timing:
– At admission (< 20 min)
– After maximum 60 min
– At discharge

9. Failure to assess initial pain
• A study conducted by Marquee and colleagues showed that
physicians gave significantly lower pain ratings than
patients both on arrival and at discharge
• The extent of “miscalibration” was greater with expert
than general practitioner
Marquié L, Raufaste E, Lauque D, Mariné C, Ecoiffi er M, Sorum P. Pain rating by patients and
physicians: Evidence of systematic pain miscalibration. Pain. 2003;102:289–296.
There was a statistical significant difference between
nurse and Emergency Physicians pain judgement
(p<0.001).
During ED visit

10. • Wilder-Smith recently demonstrated
–< 1/3 of anaesthesiologists and surgeons
questioned use scores to evaluate pain
–Only 1/10 use clinical practice guidelines (CG)
Wilder-Smith OHG, Möhrle JJ, Martin NC. Acute pain management after surgery or in the
emergency room in Switzerland: a comparative survey of Swiss anaesthesiologists and
surgeons. Eur J Pain. 2002;6:189–201.

11. Acute pain in adults admitted to the emergency
room: Development and implementation of
abbreviated guidelines
• Based on Modification guidelines from US, France,
Australia abbreviated algorithm ( AA )
• Pain was assessed using either a visual analogue scale
(VAS) or a numerical rating scale (NRS) at ER admission
and again during the hospital stay
• Patients were treated with paracetamol and/or NSAID
(VAS/NRS <4) or intravenous morphine (VAS/NRS 04)
SWISS MED WKLY 2 0 0 7 ; 1 3 7 : 2 2 3 – 2 2 7

12. Thousands of copies were distributed in
the emergency rooms of regional hospitals
and an adapted form
was distributed to medical students and to
physicians in general practice throughout
Switzerland

13. Acetaminophen
• Inhibition of prostaglandin synthesis in the central
nervous system
• Doses: 2-3 g/24 hr (4-6g)?
• Routes: oral, intravenous
• Contraindications: in patients with heavy alcohol use
acute/chronic hepatitis
• Part of a multimodal analgesic regimen

14. Ibuprofen
Ketoprofen
Diclofenac
Meloxicam
Nimesulide
Celecoxib
Rofecoxib
Valdecoxib
Acetosal
Ketorolac
Indomethacin
Piroxicam
non-
selective
COX
inhibitor
preferentially
COX-2
selective
inhibitor
COX-2
selective
inhibitor
COX-1
selective
inhibitor
preferentially
COX-1
selective
inhibitor
COXIB
analgesic
anti-inflammatory
Less GI side effects
More GI side effects

15. • 54.2% received non steroid anti inflammatory drug
(NSAID), 12.2% received paracetamol and 9.9%
tramadol, only 5.6% received morphine
• Patient ’s satisfaction at one-week follow-up was as
follows: in 63% of patients pain was completely
absent, but on the other hand, 37% of patients
had no pain relief, despite analgesic therapy
prescription

16. NSAIDs and Paracetamol
• Display a ceiling effect for analgesia (not as
effective as opioids)
• Can be used in combination with opiate
analgesics (summation effect)
• Paracetamol can be used in combination with
NSAID

17. Opioids
• For managing moderate/severe acute pain and
chronic pain
• Specific opioid selection guided by intensity and
duration of pain, tolerance and safety
• Recommendation: in combination with
acetaminophen and NSAID
• Administration of meperidine is discouraged
• Parenteral opioids  used by titration 
monitoring

18. NNT – Post operative pain

19. Regional nerve block
• Cost effective
• Provide long and good quality analgesia
• Few side effects
• Central and peripheral blocks
• Ultrasound guidance ± neurostimulation

20. General Considerations
• No recommendations can anticipate all patient
responses to medications
• Believe the patient when they complain of pain
• Provide care while minimizing risk of side effect as
much as possible
– Do not withhold care solely due to unproven
suspicions
– It may be reasonable to reduce the amount of opioid
that is dispensed and to shorten time between clinical
visits and increase follow-up frequency  titration of
the opioid dose

21. General Considerations
• In emergency or disaster situations, care
may focus on
–Maintaining analgesia when necessary 
use in combination  multimodal analgesia
–Meeting needs for short term
continuation of opioids
–Taking initial steps toward reestablishing
long term care

22. Pain in Emergency !
• Pain is the important cause for re attendance in the
ED
• Pain as the fifth vital sign
• SHOULD BE MONITORIZED
• Pain level must be reassessed after first therapeutic
gesture
• Pain might lead to immediate and long term side
effects

23. Result from some studies
Pain management in Emergency
• Pain intensity is high in emergency patients and after
discharge
• Analgesics administration are delayed
• The follow up of pain assessment were not done in
most of emergency patients
• IM routes  used in a high proportion of cases
• Lack of communication between patients and cara giver
• Many emergency patients have chronic pain  not
properly manage
• Significant proportion of patients  experienced
persistent pain leads to functional interference

24. Conclusions
• 74% of patients discharge home with moderate to severe
pain  with or without treatment before
• ED patients should receive proper pain management,
avoiding delays such as those related to diagnostic testing
or consultation
• In order to further improve patient care we must now apply
our knowledge regarding acute and chronic pain
treatment base on pharmacology of the drugs

25. Conclusions
• Ongoing research in the area of ED patient pain
management conducted and an algorythm or clinical
guidelines in this area should be developed
• Effective physician and patient educational strategies
should be developed regarding pain management,
including the use of pain therapy adjuncts and how to
minimize pain after disposition from the ED