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REVIEW ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 3  |  Page : 175-178

Acute pain management


Department of Emergency Medicine, Excel Care Hospital, Guwahati, Assam, India

Date of Submission19-Apr-2021
Date of Decision01-May-2021
Date of Acceptance08-May-2021
Date of Web Publication05-Jul-2021

Correspondence Address:
Dr. Premranjan Mohanty
Department of Emergency Medicine, Excel Care Hospital, Guwahati - 781 033, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_38_21

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  Abstract 


Pain has been described as one of the leading causes of morbidity worldwide and is one of the most significant contributors to absence from work and thereby a decrease in productivity. Acute pain is frequently neglected and undertreated both in the emergency department (ED) and in the postoperative period. The management of acute pain is very often inconsistent and inadequate relative to the degree of pain perceived by the patient. This also results in reduced patient satisfaction, readmissions, and delayed recovery in postoperative patients. Suboptimal analgesia is frequently a result of certain barriers, at the physician level as well as patient level. In the setting of an ED, the key to solving the problem of oligoanalgesia starts with the acknowledgment and assessment of pain, involving the treating physicians, nurses, and the other emergency medical service providers.

Keywords: Acute pain, oligoanalgesia, pain relief, postoperative pain


How to cite this article:
Mohanty P. Acute pain management. Curr Med Issues 2021;19:175-8

How to cite this URL:
Mohanty P. Acute pain management. Curr Med Issues [serial online] 2021 [cited 2021 Dec 4];19:175-8. Available from: https://www.cmijournal.org/text.asp?2021/19/3/175/320652




  Introduction Top


Pain has been described as one of the leading causes of morbidity worldwide and is one of the most significant contributors to absence from work and thereby a decrease in productivity.[1] Acute pain is frequently neglected and undertreated both in the emergency department (ED) and in the postoperative period. The management of acute pain is very often inconsistent and inadequate relative to the degree of pain perceived by a patient. This also results in reduced patient satisfaction, readmissions, and delayed recovery in postoperative patients.[1],[2]

Suboptimal analgesia is frequently a result of certain barriers, at the physician level as well as patient level.[2] There is a markedly prevalent lack of education and emphasis on the management of acute pain in medical and nursing curricula. This leads to a physician overlooking pain relative to a patient's somatic symptoms and thereby undertreating it. Quality indicators governing patient care often do not take into consideration adequate pain management as an outcome which contributes to overall patient care. This lack of review leads to the lacunae in the system not being exposed and addressed. There is also a void in the amount of research and information that places special emphasis on certain vulnerable populations, such as the pediatric and geriatric populations, who present with a different threshold to pain and response to analgesia. Physicians are already known to be prisoners to a certain degree of “opiophobia,” whereby there is an unwarranted avulsion toward the use of opioid analgesics due to a fear of misuse of narcotic drugs. Other reasons for inadequate analgesia usually include variability in the interpretation of the degree of pain as perceived by different physicians and as amusing as it may sound, “bias and disbelief about pain reporting due to ethnic and racial stereotyping.”[2],[3]

Educating the treating physician toward appropriate assessment of the patient's pain perception remains the core strategy in reducing oligoanalgesia. In the setting of an ED, the key to solving the problem of oligoanalgesia starts with the acknowledgment and assessment of pain, involving the treating physicians, nurses, and the other emergency medical service providers. Protocol-based pain management in the ED has two important prerequisites in the form of documentation of preprotocol pain (using numerical scales or visual analogs) and postprotocol evaluation of outcomes.[4],[5]

Assessment of severity of pain

It is of utmost priority to assess the severity of pain as soon as a patient presents to the ED with traumatic or nontraumatic pain. The Universal Pain Assessment Tool (UPAT) is an easily available and validated tool for assessing the severity of pain in patients with normal mentation [Figure 1]. This combines pictures (Wong–Baker faces) and numbers for pain rating. The grading is as follows: 0 indicates no pain, while 10 indicates very severe pain. The patient is asked to point out the picture that best describes the severity of the pain or the numerical value of the severity of pain he/she is currently experiencing.[6],[7]
Figure 1: Universal pain assessment tool.

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  • Verbal numeric rating scale: 0–10
  • No pain - 0. Worst pain - 10.


The UPAT is illustrated in [Figure 1]. The tool to assess pain score is used at admission and 30 min after administration of analgesics to target a pain score of less than 4.


  Pain Protocol in the Emergency Department Top


A patient's pain score must be assessed as the time of initial presentation to ED and at regular intervals thereafter. Pain score is best assessed every 30 min after intravenous (IV) analgesic till target score is achieved. After this, pain score should be assessed every 1 h for at least 4 h.

The following analgesics are commonly used for providing acute pain relief in the ED. It is advisable to be generous with administration of analgesics to trauma victims.

Morphine

It is a very potent opioid analgesic that can be administered orally, intravenously, or intramuscularly. The initial dose is 0.1 mg/kg bolus followed by 0.05 mg/kg every 30 min for a maximum of 3 doses.[4],[8],[9]

  • Avoid in traumatic brain injury, biliary colic, and history of allergy
  • Watch for sedation, decrease in respiratory rate, hypotension, and vomiting.


Fentanyl

A derivate of phenylpiperidine, fentanyl is a potent opioid analgesic, with an almost immediate action, which makes it ideal for patients with severe pain. The initial dose is 1–2 μg/kg bolus followed by 1 μg/kg every 30 min for a maximum of three doses.[4],[10],[11]

  • Avoid in traumatic brain injury, biliary colic, and history of allergy
  • Watch for sedation, decrease in respiratory rate, and vomiting.


Tramadol

An opioid analgesic, tramadol can be used for moderate-to-severe pain and may be of particular benefit for patients with mixed nociceptive and neuropathic pain. The initial dose is 2–3 mg/kg bolus (maximum 150 mg).[4],[12],[13]

  • Avoid in patients on antidepressants or with history of seizures, biliary colic, and history of allergy
  • Watch for seizures and vomiting.


Paracetamol

The most commonly used over-the-counter analgesic, paracetamol is effective for mild-to-moderate pain. It can be used in all patients without renal and hepatic injury. The initial dose is 15–20 mg/kg bolus in 100 mL NS, and the dose can be repeated every 6 h (without hepatic injury).[4],[14],[15]

Nonsteroidal anti-inflammatory drugs

These are a class of drugs with both analgesic and anti-inflammatory properties and have the advantage of a significant opioid dose-sparing effect. They do not cause sedation or respiratory depression and have no risk of dependence or addiction. Examples include diclofenac, aceclofenac, ibuprofen, and naproxen. Common side effects include gastrointestinal (GI) irritation, platelet dysfunction, and renal dysfunction. Contraindications include active gastrointestinal ulcers or active GI bleeding, cerebrovascular accident, bleeding disorders, renal failure (CrCl <30 mL/min), and severe decompensated heart failure.[11],[15]


  Procedural Sedation in the Emergency Department Top


Procedural sedation involves the use of short-acting analgesics and sedatives to perform procedures effectively, while monitoring for potential adverse effects. Propofol, benzodiazepines (midazolam), etomidate, ketamine, fentanyl, and ketofol (ketamine + propofol) are usually used.

Ketamine

It is a general anesthetic that provides sedation, analgesia, and amnesia. It causes dissociative anesthesia by causing dissociation between the thalamocortical and limbic systems. The onset of action is 1–2 min, and the duration of action is 10–20 min.[16],[17],[18]

Dose

  • Usual induction dose is 1–2 mg/kg over 1–2 min
  • Doses of 0.25–0.5 mg/kg may be repeated every 5–10 min thereafter.


Contraindications

  • Raised intracranial pressure
  • Severe systemic hypertension
  • Raised intraocular pressure
  • History of seizures or psychosis.


Side effects

Tachycardia, hypertension, laryngospasm, emergence reactions (disorientation, hallucinations, and nightmares), hypersalivation, nausea, and vomiting.

  • Glycopyrrolate (5 μg/kg) or atropine (0.5–1 mg) may be given for hypersalivation
  • Midazolam 1–2 mg may be used for treating or preventing emergence reactions
  • Laryngospasm: Attempt to break the laryngospasm by applying a painful inward and anterior pressure at the “Larson's point”/”laryngospasm notch,” which is located near the top of the ramus of the mandible. Laryngospasm can also be reduced by deepening the sedation with a low dose of propofol.


Midazolam

It is a short-acting benzodiazepine that provides anxiolysis and amnesia, without analgesia.[19]

Dose

  • 0.02–0.03 mg/kg slow IV bolus
  • Repeat doses may be given every 2–5 min as necessary.
  • Maximum single dose is 2.5 mg and maximum cumulative dose is 5 mg
  • The onset of action is 1–2 min, and the duration of action is 30–60 min.


Side effects

  • Respiratory depression and hypotension
  • Action reversed by flumazenil.


Fentanyl

It provides analgesia without any amnesia or anxiolysis. It is a synthetic short-acting opioid that has 75–125 times the potency of morphine. The onset of action is 1–2 min, and the duration of action is 30–60 min.[9],[10]

Dose

  • 0.5–1 μg/kg slow IV push every 2 min, until an appropriate level of sedation and analgesia is achieved
  • The maximum total dose is 5 μg/kg or approximately 250 μg.


Side effects

  • Respiratory depression and hypotension (rare)
  • Naloxone may be used to reverse respiratory depression.


Local anesthetic (lignocaine) infiltration

Regional anesthesia is an integral part of acute pain relief to trauma victims. Peripheral nerve blocks significantly alleviate pain and improve patient comfort. In addition, they reduce the requirement for systemic opioid analgesia, thereby minimizing the adverse effects associated with opioid use.[20],[21] The choice of the local anesthetics depends on the desired duration of the block. 2% lignocaine is used for shorter duration of blockade, while 0.5% bupivacaine is used for longer blockade.

Protocols also involve shedding the fears surrounding the use of opioid analgesia and even using nerve blocks to achieve pain relief in an emergency setting. Frequent in-house audits and external reviews will be needed to constantly improve the quality of adequate and appropriate time-bound analgesia in ED. A few hospitals have a dedicated “pain call,” which is usually an on-call anesthetist, responsible for assessing the degree of pain and optimizing analgesia for the inpatients. The position is an improvisation in itself, which offers versatility in improving outcomes in postoperative patients.


  Conclusion Top


Every ED must have a pain protocol that is strictly adhered to. With pain being recognized worldwide as a definitive predictor of morbidity, it is imperative that the focus on acute pain management is impressed upon trainees as earliest as possible during the days of training. It will go a long way in addressing the elephant in the room.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patil A, Srinivasarangan M, Ravindra P, Mundada H. Studying protocol-based pain management in the emergency department. J Emerg Trauma Shock 2017;10:180-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Ann Emerg Med 2004;43:494-503.  Back to cited text no. 2
    
3.
Miner J, Biros MH, Trainor A, Hubbard D, Beltram M. Patient and physician perceptions as risk factors for oligoanalgesia: A prospective observational study of the relief of pain in the emergency department. Acad Emerg Med 2006;13:140-6.  Back to cited text no. 3
    
4.
Muthyala SK, Lohanathan A, Thampi SM, Singh K. Pain management in acute trauma. Curr Med Issues 2020;18:222-8.  Back to cited text no. 4
  [Full text]  
5.
Cohen SP, Christo PJ, Moroz L. Pain management in trauma patients. Am J Phys Med Rehabil 2004;83:142-61.  Back to cited text no. 5
    
6.
Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 2001;8:1153-7.  Back to cited text no. 6
    
7.
Keck JF, Gerkensmeyer JE, Joyce BA, Schade JG. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. J Pediatr Nurs 1996;11:368-74.  Back to cited text no. 7
    
8.
Patanwala AE, Duby J, Waters D, Erstad BL. Opioid conversions in acute care. Ann Pharmacother 2007;41:255-66.  Back to cited text no. 8
    
9.
Patanwala AE, Keim SM, Erstad BL. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother 2010;44:1800-9.  Back to cited text no. 9
    
10.
Vahedi HS, Hajebi H, Vahidi E, Nejati A, Saeedi M. Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury. World J Emerg Med 2019;10:27-32.  Back to cited text no. 10
    
11.
Abdolrazaghnejad A, Banaie M, Tavakoli N, Safdari M, Rajabpour-Sanati A. Pain management in the emergency department: A review article on options and methods. Adv J Emerg Med 2018;2:e45.  Back to cited text no. 11
    
12.
Bamigbade TA, Langford RM. Tramadol hydrochloride: An overview of current use. Hosp Med 1998;59:373-6.  Back to cited text no. 12
    
13.
Cossman M, Kohnen C. General tolerability and adverse event profile of tramadol hydrochloride. Rev Contemp Pharmacother 1995;6:513-31.  Back to cited text no. 13
    
14.
Jefferies S, Saxena M, Young P. Paracetamol in critical illness: A review. Crit Care Resusc 2012;14:74-80.  Back to cited text no. 14
    
15.
Todd KH, Ducharme J, Choiniere M, Crandall CS, Fosnocht DE, Homel P, et al. Pain in the emergency department: Results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain 2007;8:460-6.  Back to cited text no. 15
    
16.
Davis WD, Davis KA, Hooper K. The use of ketamine for the management of acute pain in the emergency department. Adv Emerg Nurs J 2019;41:111-21.  Back to cited text no. 16
    
17.
Nichols KA, Paciullo CA. Subdissociative Ketamine Use in the Emergency Department. Adv Emerg Nurs J 2019;41:E1.  Back to cited text no. 17
    
18.
Pourmand A, Mazer-Amirshahi M, Royall C, Alhawas R, Shesser R. Low dose ketamine use in the emergency department, a new direction in pain management. Am J Emerg Med 2017;35:918-21.  Back to cited text no. 18
    
19.
Neuman G, Swed Tobia R, Koren L, Leiba R, Shavit I. Single dose oral midazolam for minor emergency department procedures in children: A retrospective cohort study. J Pain Res 2018;11:319-24.  Back to cited text no. 19
    
20.
Choi JJ, Lin E, Gadsden J. Regional anesthesia for trauma outside the operating theatre. Curr Opin Anaesthesiol 2013;26:495-500.  Back to cited text no. 20
    
21.
Hughes S, Birt D. Continuous peripheral nerve blockade on OP HERRICK 9. J R Army Med Corps 2009;155:57-8.  Back to cited text no. 21
    


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