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<< An Evidence-Based Approach To Traumatic Pain Management In The Emergency Department (Trauma CME)

Emergency Department Evaluation

Appropriate treatment of pain is predicated on an ability to assess the pain. Documentation of pain assessment is mandated by the Joint Commission.35,36 Unfortunately, assessment is often challenging for a variety of reasons. These may include cultural or language differences,37,38 mental status changes, inability to communicate, critical illness39 and developmental stage, to name a few. There are few reliable objective measures to quantify pain. Vital signs often remain normal despite a significant degree of pain.40 Owing to the subjective nature of the experience of pain, patient and clinician assessment of pain differ.41 Furthermore, it has been suggested that pain assessment tools are underutilized42,43 despite demonstration that rapid pain assessment is associated with decreased time to analgesic administration.44

There are many methods of evaluating pain. One of the simplest is a Verbal Rating Scale (VRS), which asks the patient to select the most appropriate description of the pain from a set of predefined descriptors (eg, no pain, mild pain, moderate pain, severe pain, or unbearable pain). A similar Verbal Descriptor Scale was developed by Tanabe et al.43 A Visual Analog Scale (VAS)45-47 is a method that has gained popularity, especially among researchers. It has the patient make a mark along a continuum to estimate the severity of pain. It is especially useful for measuring differences, as it is less hindered by discrete values. Thirteen millimeters has been determined to represent a significant difference,48,49 although one study suggested that 9 millimeters is adequate.50 These differences, however, are not necessarily a linear correlation, and pain relief at the lower range may not correlate with pain relief at the higher range.51,52

Another common method of assessment is a Verbal Pain Score or Numerical Rating Scale (NRS),53,54 which simply asks a patient to rate pain experience on a scale from 0 to 10. Unfortunately, this relies on an understanding of numbers and an ability to give a response. The NRS is preferred for trauma patients as it correlates with VAS and VRS, and it has a preferable response rate (96% vs 39%).55 Kendrick et al determined in 2005 that a difference of 1.39 was significant.56

Children pose additional difficulty with pain assessment, as they may have barriers with language development and may have difficulty discerning anxiety from pain (a situation not unique to the pediatric population). The Wong-Baker FACES™ pain rating scale, which is essentially a verbal pain score with added illustrations, may be useful for verbal children. Pain assessment scores like the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)57 and the Face, Legs, Activity, Cry, Consolability (FLACC) scale58 have been validated to aid with assessment of preverbal children. Other scales that include elements such as colors, facial expressions, and numbers have also been studied.59

Critically ill and intubated patients pose additional difficulties with pain assessment due to these patients’ limited ability to communicate. Vital sign derangements (eg, tachycardia or hypertension) are sometimes used to approximate discomfort, but these are notoriously unreliable.40 The Critical Care Pain Observation Tool (CCPOT) has been developed as a means to estimate pain sensation using physiologic characteristics (blood pressure, heart rate, respiratory rate, and oxygen saturation) as well as self-reporting, when possible. It was prospectively validated by Gélinas et al in 55 intensive care unit patients, showing good interrater reliability.60

Patients with dementia also pose difficulty with assessment, and a Pain Assessment in Advanced Dementia (PAINAD) scale has been developed, which relies on objective measures of discomfort including comfort of breathing, vocalization, facial expression, body language, and consolability.61 Like the CCPOT, it is useful for patients who are unable to effectively communicate or express their discomfort, and it showed similar performance in 100 nonverbal critical care patients in a study by Paulson-Conger et al.62

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Last Modified: 12/12/2017
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