Chapter 26 Pain Management in the Emergency Department

Question 1

Patients with chronic pain can be divided into four general groups

Answer 1

These groups are patients with chronic pain secondary to underlying diseases such as cancer, sickle cell disease, and AIDS;
patients with known pain syndromes such as tic douloureux and migraine headache;
chronic pain patients without an identifiable cause; and finally, the
group of patients who uses the complaint of chronic pain to obtain drugs or for other personal gains

Question 2

butorphanol (Stadol)

Answer 2

has good analgesic activity

but gives little euphoria

Question 3

the early control of acute pain appears to reduce the incidence of

Answer 3

chronic pain syndromes, and may improve the patient’s outcome

Question 4

Opioid available in sucker

form

Answer 4

Fentanyl is available in sucker form, which has great applicability in the pediatric population

Question 5

Opioid effective when given via the nasal mucosa

Answer 5

Sufentanil and butorphanol

Question 6

Treatment of mild to moderate migraine

Answer 6

acetaminophen or nonsteroidal agents are

often effective

Question 7

Treatment of severe and persistent migraine

Answer 7

sumatriptan given subcutaneously or by
nasal spray, or prochlorperazine or chlorpromazine by
the IV route, may be required to both relieve the pain and to counteract nausea and vomiting

Question 8

Sumatriptan is contraindicated in patients with

Answer 8

known coronary artery

disease, hypertension, pregnancy, and peripheral vascular disease

Question 9

prochlorperazine or chlorpromazine associated with

Answer 9

hypotension (give 500-cc bolus of saline prior), sedation, and dystonic reactions, and an anticholinergic drug should be added if these agents are given in high doses.

Question 10

Dihydroergotamine

Answer 10

is contraindicated in vascular disease, in the elderly, if the patient is on MAO inhibitors, and if sumatriptan has already been used. This agent is
especially useful for patients with a refractory attack of migraine, and if used, the patient should first receive an antiemetic

Question 11

Treatment of Cluster headaches

Answer 11

sumatriptan will abort the attack. High-flow oxygen will often end the attack. If these attempts fail, dihydroergotamine given by
the IV route is effective.

Question 12

Nonsteroidals are contraindicated in the treatment of patients with suspected SAH

Answer 12

because of their anticoagulation properties.

Question 13

Subarachnoid Hemorrhage

Answer 13

patients describe the headache as if their head is exploding, or that the top of their head felt as if it was going to come off. These patients will frequently
state that this is or was the worst headache of their life

Question 14

Tension Headache

Answer 14

patient complains of a band-like pressure around the head and associated neck stiffness

Question 15

Tension Headache Treatment

Answer 15

Pain relief can usually be
achieved with acetaminophen or nonsteroidals. If there is
associated anxiety, mild tranquilizers may help to prevent recurrence

Question 16

Three most common

serious diseases presenting with chest pain

Answer 16

myocardial
ischemia and infarction, pulmonary embolism, and dissection
of the thoracic aorta

Question 17

treatment of three most common serious diseases presenting with chest pain

Answer 17

myocardial
ischemia and infarction: morphine ,
pulmonary embolism; good pain relief can usually be obtained with
NSAIDs. Opioids are safe and effective, if required, dissection of the thoracic aorta : opioid

Question 18

In patient who presents with chest pain, where NSAIDs should be avoided

Answer 18

gastroesophageal reflux disorder (GERD). Acetaminophen may be used, but primary treatment with antacids and histamine blockers should be initiated.

Question 19

commonly used muscle relaxants

Answer 19

orphenadrine

citrate, methocarbamol, and the benzodiazepines

Question 20

oral opioids are effective

in the management of severe pain,

Answer 20

hydrocodone, oxycodone, and oral meperidine.

Question 21

Patients given IV opioids need to be monitored

for

Answer 21

respiratory depression, hypotension, and excessive

euphoria.

Question 22

Fentanyl

Answer 22

is a short-acting opioid with high potency and minimal cardiovascular effects. This agent has a rapid onset of action, usually within 2 min, and the duration of action is 30 to 40 min. Serum half-life is approximately 90 min. This combination of rapid onset, high potency, and short half-life makes fentanyl an excellent
agent for most ED procedures

Question 23

Fentanyl Dosage

Answer 23

The usual required
dose is between 2 and 3 mcg/kg by slow IV push given in increments of 0.5 to 1 mcg/kg every 2 min to a max of 5 mcg/kg for both adults and children

Question 24

Fentanyl Side Effects

Answer 24

muscular and glottic
rigidity or chest rigidity (reversed by either naloxone or succinylcholine.) Seizures, General pruritus is not
present with the use of fentanyl as occurs with many opioids, as it does not cause histamine release, and nausea is
usually minimal

Question 25

Fentanyl Lollipop

Answer 25

Fentanyl can also be administered orally in the form of a lollipop, making it useful in children if the IV route is not possible or required. The dose is usually 10 to 15 mg/kg,
and onset of action is between 12 to 30 min. Nausea and vomiting are more common

Question 26

Midazolam

Answer 26

The usual dose is 0.02 to 0.1 mg/kg for adults
and 0.05 to 0.15 mg/kg for children. Midazolam also has a rapid onset of action of 1 to 3 min and a relatively short half-life of 30 to 60 min

Question 27

Midazolam effects

Answer 27

excellent sedation, a beneficial hypnotic effect, muscle relaxation, amnesia, and antiseizure activity

Question 28

The major side effect of midazolam

Answer 28

respiratory depression,

Question 29

Cardiovascular effects of Midazolam

Answer 29

In general, cardiovascular side effects are not seen at sedative dosages. If other agents, such as fentanyl, are used in combination with midazolam, hypotension may occur

Question 30

Routes of administration of Midazolam

Answer 30

midazolam may be administered by

rectal suppository, orally, and by nasal insufflation.

Question 31

combination of fentanyl and midazolam

Answer 31

midazolam 0.02 mg/kg IV and fentanyl 0.5 mcg/kg IV. Repeat one or both agents as needed every 2 min

Question 32

relative contraindications

of Ketamine

Answer 32

The presence of

cardiovascular disease, traumatic head injury, eye injury, glaucoma, and hyperthyroidism is a

Question 33

What is the most serious complication in children with Ketamine?

Answer 33

Laryngospasm is a serious complication in children, especially in those less than 3 months old, and it should not be used in this age group. Laryngospasm
rarely occurs in children older than 3 months

Question 34

Routes of administration and Dosage of Ketamine

Answer 34

Ketamine can be given by all routes of administration, including IM. The IV route is the easiest to titrate, and the dose required is 1 to 2 mg/kg by the IV route. Onset of action is within 1 min of IV infusion, and the duration of action is only 15 min

Question 35

Infusion of Ketamine

Answer 35

In adults, prolonged procedures require a constant infusion of ketamine at the rate of 1 to 2 mg/kg/hr, while in
children repeated small doses of 0.05 to 0.1/kg are given as required

Question 36

Indications of Ketamine

Answer 36

This agent is an excellent first-line agent in the
pediatric population, and is a good alternative to opioids in adults allergic to opioids, and for patients at risk of hypotension
and respiratory problems

Question 37

Etomidate

Answer 37

is an ultra–short-acting non-barbiturate hypnotic imidazole with minimal cardiovascular effects. It is administered at 0.1 to 0.15 mg/kg IV over 30 to 60 sec and redosed every 3 to 5 min. Its onset of action is almost immediate and effect lasts 5 to 15 min

Question 38

Side Effects of Etomidate

Answer 38

One side effect is myoclonus, which may occasionally interfere
with an intended procedure. Adrenal suppression may
also occur with even one dose, so this agent should be avoided in septic and multitrauma patients. Injection pain is common and may be avoided by cannulating a large vein or applying a tourniquet proximally and injecting
0.5 mg/kg lidocaine IV 30 to 120 sec prior to the
etomidate injection

Question 39

Propofol

Answer 39

Propofol is a unique ultra–short-acting anesthetic agent unrelated to any other anesthetic class.40 It is administered by slow injection of an initial loading dose of 0.5 to 1 mg/kg
IV followed by 0.5 mg/kg IV every 3 to 5 min as needed. Anesthesia occurs within 40 sec and lasts 6 min

Question 40

Absolute contraindications of Propofol

Answer 40

Absolute contraindications include hypersensitivity to egg lecithin and soybean oil. Propofol can induce transient hypotension so should be used with caution in patients with hypovolemia, hypotension, or poor cardiac function

Question 41

Allergy to Local Anesthetics

Answer 41

history of allergy to these agents, almost invariably it will be to the ester class.

Question 42

EMLA, a eutetic mixture of local anesthetic agents.

Answer 42

This compound comes in cream form and
the active ingredients are lidocaine and prilocaine. The cream is applied directly to the laceration under an occlusive
dressing without pain to the child. Within 30 to 60 min complete anesthesia can be obtained which will last up to 5 hr.

Question 43

Lidocaine (Xylocaine, Dilocaine, Ultracaine

Answer 43

Amide

Blocks, infiltration. Onset rapid. Duration 90–200 min

Question 44

Tetracaine (Pontocaine)

Answer 44

Ester

Spinal, topical, eye. Onset slow. Duration 180–600 min

Question 45

Mepivacaine (Carbocaine)

Answer 45

Amide

Epidurals, blocks, infiltration. Onset very rapid. Duration 120–240 min

Question 46

Bupivacaine (Marcaine)

Answer 46

Amide

Blocks. Onset intermediate. Duration 180–600 min

Question 47

Procaine (Novocaine, Neocaine)

Answer 47

Ester

Blocks, infiltrations. Onset slow. Duration 60–90 min