Pain and pain management

Stratford Upon Avon First Aid 1
Pain Management

Pain and Pain Management
• Pain is the most common symptom
causing patients to seek medical attention
yet most formal training is primarily
concerned with treating injuries and illness
with hardly any time spent on how to
manage the pain itself.

• In many instances correct treatment of the
injury or illness will reduce pain as a
consequence; cooling a burn, stabilising a
joint injury or correctly positioning a
casualty with chest pain, for example, will
in effect reduce pain as well as correcting
the cause for concern.

• Sometime this is not enough, sometimes
the cause is obvious but sometimes the
casualty just presents with ‘pain’. No
apparent injury, no history of illness. How
do you treat that?
• Sometimes, even after initial treatment,
the casualty is still in pain. Definitive care
is over 12 hours away. What do we do
then?

• Pain in itself is not life threatening but pain
can cause physiological changes in blood
pressure, breathing and pulse. This is
interesting but the main reason that I want
to manage a casualty’s pain, is for
compliance:
• A pain-free casualty will be
• more compliant

• more willing to engage in their own
treatment
• less dependent on others
• easier to move and transport
• more willing to accept potentially painful
procedures such as examination or wound
cleaning, for example.

• Better rested with less disturbed sleep,
less stressed and generally a nicer person
to be around. This is especially important
in remote areas when living in small
groups or teams and in confined areas!

What is Pain?
• Pain has two primary
etiologies: nociceptive and neuropathic.
The difference is whether the pain
stimulus comes from a nerve receptor,
intended to sense pain, touch,
temperature, or pressure (nociceptive); or
if the pain stimulus comes directly from
injury to the nerve itself (neuropathic).

What is Pain?
• Nociceptive pain, for example, is the pain
that occurs when you hit your thumb with a
hammer. The impact stimulates the nerve
receptors, sending pain signals to the
brain. If you push on the area of pain, it
will make the pain worse.

What is Pain?
• Neuropathic pain, on the other hand, is
radiating pain that occurs when a nerve
itself is injured. For example, the casualty
may have ruptured a disk in their lower
back, and that disk is now compressing
the left L5 nerve root of the sciatic
nerve. As a result, they will have pain that
radiates down the back of their leg to their
foot.

What is Pain?
• When you push on the areas of apparent
pain – the foot - it does not cause more
discomfort because the problem is at the
disc, not where the pain is presenting.

What is Pain?
• Nociceptive pain is easily managed with
non-steroidal anti-inflammatory drugs
(NSAIDs),paracetamol (acetaminophen in
the US) and opioids. Neuropathic pain
does not respond to these usual pain
relievers, making it much harder to control.

Assessing Pain
• Pain is incredibly subjective and the term
‘pain’ is wildly vague. For the casualty to
say “I’m in immense pain!” tells me nothing
other than something is not normal. A
critical, structured approach can help
gather more detailed and
relevant information:
PQRST

Provocation
• What caused the pain?
• Does anything aggravate the pain?

Quality
• Can you describe the pain? Is it a dull
ache, a sharp stabbing pain, a vice-like
gripping pain or a numb tingly pain, for
example?

Radiates or Refers
• Some pain radiatesoutwards; is the pain
spreading? Neuropathic pain will ‘refer’
i.e. the pain is felt elsewhere. A common
example is the pain felt in the tip of the left
shoulder pain which can be indicative of
an ectopic pregnancy. This would be
worth considering if the casualty was a
sexually active female of child-bearing
age. Less so if your casualty is male.

Severity
• Because pain is so subjective, to describe
the intensity is practically worthless; a
paper-cut can be agony to one person or a
mild annoyance to another. A more
representative assessment would be to
ask the casualty to score the pain out of
10 (10 being the worst possible
pain). This again is a worthless value on
its own as it is simply one person’s
opinion.

Severity (Continued)
• However, if this question is repeated a
change in the value stated will indicate an
increase or decrease in pain. This is
particularly useful if dealing with casualty’s
for an extended period of time, after
treating an injury or after administering
pain relief.

Time
• When did it start?
• Is it constant or does it come and go?

Assessing Pain
• The answers you get may enable you to
make an informed decision or they may
not mean anything to you.
• They will mean something to someone so
whether you understand the answers or
not, all communication is documented
and handed over to definitive care.

Mechanisms of Pain Control
• There are several methods we can employ
to help reduce pain:
• Non-medicated pain control:
– Minimize and control swelling of the tissues
by RICE
– Additional techniques
• Medicated pain control:
– Analgesics
– Specific medications

Non-Medicated Pain Control
• Pain can be reduced, to some degree,
without the need of medications. The
most effective and widely used techniques
is the application of RICE
• Rest: Rest or completely immobilise the
injured area to minimize movement.

• Ice: Apply cool compresses to the affected
area to cause vasoconstriction, reducing
swelling and thus reducing pain. This also
minimizes any further bleeding into the
damaged tissue. Ice is a metaphor for
cool – NEVER apply ice directly to skin.

• If you have ice available (from a drinks
bucket, a bag of frozen peas or even snow
or ice itself), wrap the ice in something wet
which will conduct heat quickly but will
reduce the chance tissue damage.

• A regime of a maximum of 15 minutes
cooling in every hour is used to ensure
vasoconstriction does not lead to frostbite
in the effected limb and, furthermore,
alternate cooling and rewarming is more
effective than continual cooling as the
affected area also needs a good supply of
blood to remove waste products and
promote healing.

• Comfortable position: Historically the
“C” has always stood for Compression but
there are inherent risks in applying
compression dressing to a swollen injury
or injury which may continue to swell.

• This is largely academic as the casualty
will probably not allow you to apply a
compression dressing, in which case
allowing them to adopt the most
comfortable position is far more beneficial
in terms of reducing pain and promoting
recovery. Don’t worry about whether they
should be in a high arms sling or a low
arm sling – bind as you find!

• Elevation: Elevate the injured area above
the level of the heart. This lowers the
blood pressure and decreases the rate
that blood leaks into the damaged tissue
and further reduces swelling.
• Addition techniques
• In addition to RICE, pain may also be
managed by:

• Positioning – There are many recognised
positions for a casualty which are said to
reduce pain or promote recovery with
exciting names such
as Trendellenberg and Reversed
Recumbent. The casualty will adopt their
own position. Most people with abdominal
pain will bring their knees up and curl up in
the foetal position.

• Casualties suffering with chest pain or
breathing conditions will prefer NOT to lie
down, so don’t make them. Support the
casualty in the position they adopt.

• Reassurance – Pain is a physiological
response to either the stimulus of nerve
receptors or the presence of chemical
mediators but the perception of pain can
be exacerbated or suppressed depending
on the level of emotional support provided
to the casualty. Do not underestimate the
value of emotional support.

• Distraction – By the same token, do not
do everything for the casualty. The best
way to make someone feel helpless is to
treat them as though they are. Engaging
the casualty in their own treatment and
keeping them occupied is an effective
method of distraction.
• Traction can relieve pain but training is
essential.

Medicated Pain Control
• There is a lot if myths which are still
promulgated in society in general and on
some formal training courses:
• It is not illegal to give an adult a simple
pain relief such as aspirin
or paracetamol as long as it is done
correctly. It is not illegal to give a child
medication as long as it is both done
correctly and there is parental consent.

• To leave tablets in front of a casualty and
say "I'm just going to leave the room, if
you choose to take some I won't say a
word, nudge nudge wink wink“
• DOES NOT ABSOLVE YOU OF
RESPONSIBILITY.

• Many people think that because we cannot
give pain killers to casualties, if we
suggest they take them themselves there
is no harm done. THIS APPROACH
MAKES YOU NEGLIGENT.

• If the casualty is in pain, you have asked
appropriate questions, you know there are
no known allergies and they have taken
the medication before, you know what
dose to give them and how often, do so
and write it down.

• To leave a casualty, who clearly wants
pain relief alone with medication YOU
have presented to them which they
otherwise would not have taken - of
course they are going to take it but this
time nothing is documented or observed.

• People arrive at A&E complaining of acute
pain. When asked by the Triage
Nurse "Have you taken any pain
relief?" they frequently reply with "No, we
didn't want to mask the pain." Take pain
relief, that is what it is for. Commonly
available over-the-counter pain relief will
not mask acute pain, it will take the edge
of and make things a little more bearable.

• We have probably all seen or
taken aspirin, paracetamol (acetaminophe
n in the US) or ibuprofen at one time, or
another, being the most widely available
pain killers. What is important is to
understand is that they are not the same:

Aspirin
• Aspirin
• A mild analgesia that is known for its
additional quality of ‘thinning the blood’. It
doesn’t actually thin the blood but it is
what’s known as a platelet aggregation
inhibitor; it inhibits blood clotting. This can
be used to good effect as prophylactic
medication at altitude or for these with
cardiac problems.

Aspirin
• Aspirin is also given immediately after a
heart attack to reduce the chance
subsequent heart attacks and reduce the
damage to cardiac muscle 1,2.
• 300mg – 600mg every 6 hours to a
maximum of 4g a day. Take with food and
avoid if there is a history of stomach ulcers
or an allergy to ibuprofen or naproxen.

Paracetamol
• A much underrated pain relief;
paracetamol is an effective pain killer to
the extent that IVparacetamol is regularly
used in A&E departments where lay-
people would commonly expect much
‘stronger’ pain relief to be used.

Paracetamol
• The interesting fact about paracetamol is
that it is known to work but no really
understands how, just that it
does! Paracetamol has additional
properties in reducing fever although
paracetamol should not be given to reduce
a fever unless it is over 40oc – the root
cause of the fever needs to be addressed.

Paracetamol
• Paracetamol – like all drugs – does not
come without warning. Paracetamol is
toxic in comparatively small amounts.
• 500mg – 1g (one to two tablets) every 4-6
hours to a maximum of 4g a
day. Paracetamolshould be avoided
where there is a history of liver problems

Ibuprofen
• Ibuprofen (or ‘brufen’) is well known as an
anti-inflammatory and therefore ideal for
bone or joint injuries however as platelet
aggregation inhibitor (although to a far
lesser degree thanaspirin) it should be
avoided in the first two days of injury as it
may promote bleeding into the tissue, in
which case start with paracetamol and
add ibuprofen if needed.

Ibuprofen
• 200mg-400mg 8 hourly – with food – to a
maximum of 1200mg a day.

Naproxen
• Naproxen is, like ibuprofen, an effective
anti-inflammatory but is better tolerated
with less stomach irritation. Naproxen is
not available over-the-counter in its
standard form but is available under the
trade name Feminax UltraTM.
• 500mg first followed by 250mg 6-8 hours
later. 250mg 8 hourly on the 2nd and 3rd
day.

Paracetamol + Ibuprofen
• Both ibuprofen and naproxen can be
combined safely to increase the efficacy to
greater effect than some
narcotics. Interestingly the addition
of paracetamol increases the analgesic
effect of both regardless of the doses of
either ibuprofen or naloxone – higher
doses of either in combination
with paracetamol is not proven to increase
analgesic effect.

Paracetamol + Ibuprofen
• 400mg ibuprofen 8 hourly (to a maximum
of 1200mg in 24hrs) + 1g paracetamol 6
hourly (to a maximum of 4mg in 24 hours)

Codeine
• Both ibuprofen and paracetamol are
currently available with codeine over-the-
counter. These represent the strongest
openly available analgesics.
• Codeine has a constipative effect so your
casualty may need to consider laxatives if
on codeine for several doses.

Antihistamines
• Clorpheniramine (PiritonTM) is primarily
used as an antihistamine for the treatment
of mild allergic reactions including hay
fever but also has a mild sedating and
analgesic effect.

Antihistamines
• In a remote setting, whilst not licensed for
the treatment of
anaphylaxis, chlorpheniramine may be of
benefit from some exhibiting a severe
reaction.

Antibiotic Creams
• Pain relief will only mask the symptoms of
eye, ear or skin infections so treat the
infection itself.

Indigestion
• If normal antacids (Gaviscon or Rennie,
e.g.) are not effective, ranitidine can be
used. Read the label.

Sore Throat
• Typical pastels have no medicine effect
other than activating saliva and tasting
sweet. Dequacaine contains a mild
anaesthetic for the most painful of sore
throats but again, it treats the symptoms,
not the cause which must also be
addressed.

Pain and pain management

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