Chapter 26 Pain Management in the Emergency Department Flashcards
KEY POINTS 1. Pain is the most common complaint seen in the emergency department. The emergency physician must ensure that patients in pain are treated with appropriate analgesics as soon as is feasible. 2. With modern diagnostic modalities, such as CT scanning, there is no reason to withhold pain medications for patients with abdominal pain. The goal is to reduce the pain for patients while they are undergoing diagnostic evaluation. Oversedation should be avoided to enable reliable physical
Patients with chronic pain can be divided into four general groups
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
butorphanol (Stadol)
has good analgesic activity
but gives little euphoria
the early control of acute pain appears to reduce the incidence of
chronic pain syndromes, and may improve the patient’s outcome
Opioid available in sucker
form
Fentanyl is available in sucker form, which has great applicability in the pediatric population
Opioid effective when given via the nasal mucosa
Sufentanil and butorphanol
Treatment of mild to moderate migraine
acetaminophen or nonsteroidal agents are
often effective
Treatment of severe and persistent migraine
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
Sumatriptan is contraindicated in patients with
known coronary artery
disease, hypertension, pregnancy, and peripheral vascular disease
prochlorperazine or chlorpromazine associated with
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.
Dihydroergotamine
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
Treatment of Cluster headaches
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.
Nonsteroidals are contraindicated in the treatment of patients with suspected SAH
because of their anticoagulation properties.
Subarachnoid Hemorrhage
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
Tension Headache
patient complains of a band-like pressure around the head and associated neck stiffness
Tension Headache Treatment
Pain relief can usually be
achieved with acetaminophen or nonsteroidals. If there is
associated anxiety, mild tranquilizers may help to prevent recurrence
Three most common
serious diseases presenting with chest pain
myocardial
ischemia and infarction, pulmonary embolism, and dissection
of the thoracic aorta
treatment of three most common serious diseases presenting with chest pain
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
In patient who presents with chest pain, where NSAIDs should be avoided
gastroesophageal reflux disorder (GERD). Acetaminophen may be used, but primary treatment with antacids and histamine blockers should be initiated.
commonly used muscle relaxants
orphenadrine
citrate, methocarbamol, and the benzodiazepines
oral opioids are effective
in the management of severe pain,
hydrocodone, oxycodone, and oral meperidine.
Patients given IV opioids need to be monitored
for
respiratory depression, hypotension, and excessive
euphoria.
Fentanyl
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
Fentanyl Dosage
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
Fentanyl Side Effects
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
Fentanyl Lollipop
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
Midazolam
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
Midazolam effects
excellent sedation, a beneficial hypnotic effect, muscle relaxation, amnesia, and antiseizure activity
The major side effect of midazolam
respiratory depression,
Cardiovascular effects of Midazolam
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
Routes of administration of Midazolam
midazolam may be administered by
rectal suppository, orally, and by nasal insufflation.
combination of fentanyl and midazolam
midazolam 0.02 mg/kg IV and fentanyl 0.5 mcg/kg IV. Repeat one or both agents as needed every 2 min
relative contraindications
of Ketamine
The presence of
cardiovascular disease, traumatic head injury, eye injury, glaucoma, and hyperthyroidism is a
What is the most serious complication in children with Ketamine?
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
Routes of administration and Dosage of Ketamine
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
Infusion of Ketamine
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
Indications of Ketamine
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
Etomidate
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
Side Effects of Etomidate
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
Propofol
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
Absolute contraindications of Propofol
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
Allergy to Local Anesthetics
history of allergy to these agents, almost invariably it will be to the ester class.
EMLA, a eutetic mixture of local anesthetic agents.
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.
Lidocaine (Xylocaine, Dilocaine, Ultracaine
Amide
Blocks, infiltration. Onset rapid. Duration 90–200 min
Tetracaine (Pontocaine)
Ester
Spinal, topical, eye. Onset slow. Duration 180–600 min
Mepivacaine (Carbocaine)
Amide
Epidurals, blocks, infiltration. Onset very rapid. Duration 120–240 min
Bupivacaine (Marcaine)
Amide
Blocks. Onset intermediate. Duration 180–600 min
Procaine (Novocaine, Neocaine)
Ester
Blocks, infiltrations. Onset slow. Duration 60–90 min
