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<< Pain Management in the Emergency Department
History
For patients presenting in pain, initial assessment focuses on whether or not an emergent condition exists: treatment of pain should not be overlooked during the initial evaluation and diagnostic work-up. A focused history should be obtained, including a thorough PMH. It is also important to assess the components of PMH that would affect the choice of medication, i.e., if a patient has a history of a bleeding ulcer, NSAIDs would not be a first choice.
Another aspect in the evaluation of the patient in pain is the psychological component. Chronic pain has been associated with depression and a desire for a “hastened death.” 59 It is important to consider the patient’s mood and affect, screening for signs of depression and suicidality as warranted. These emotional consequences of pain are also a reminder of the broad benefits to the patient when his pain is effectively controlled.
Physical
A focused physical exam includes vital signs, especially pulse, respiratory rate, and blood pressure. Stressing the importance of pain assessment, the American Pain Society has coined the phrase, “Pain: the 5th vital sign.” Studies have shown a correlation between pain and changes in vital signs, but even in acute pain the vital signs are not necessarily abnormal. Tousignant-Laflamme et al demonstrated an increase in resting heart rate with acutely painful stimuli. 60 However, it is important to note that the upper limit of the 95% confidence intervals for patient’s heart rates even at the height of acute pain in this study were still less than 100 bpm (beats per minute). While there is typically a rise in heart rate with pain, the values need not be abnormal. Selfreport should therefore be considered more indicative of the presence of pain. However, observation of a patient’s response to pain (i.e., facial expression, guarding) may be all you have to go on in a pre-verbal or cognitively impaired patient.
The extent of the physical exam depends on the type of pain; pain in an extremity directly related to an injury requires a limited exam while a patient with a nonspecific complaint of pain may require a comprehensive, systematic exam. Patients with a complaint of headache require a meticulous exam of cranial nerves II, III, IV, and VI; consideration should also be given to examining the temporal artery and assessing for vertebral or carotid dissection. A complaint of chest pain requires a careful assessment of the pulses, heart, and lungs specifically looking for evidence of pneumothorax, pulmonary embolus, pneumonia, pericarditis, and aortic dissection; a careful skin exam should be done looking for evidence of herpes zoster. The differential diagnosis of abdominal pain is extensive and the clinician must carefully perform a comprehensive evaluation in order not to miss diagnostic findings. A complaint of back pain requires a full neurologic evaluation with a focus on bowel and bladder function, motor, sensory, and reflexes.
Another aspect in the evaluation of the patient in pain is the psychological component. Chronic pain has been associated with depression and a desire for a “hastened death.” 59 It is important to consider the patient’s mood and affect, screening for signs of depression and suicidality as warranted. These emotional consequences of pain are also a reminder of the broad benefits to the patient when his pain is effectively controlled.
Physical
A focused physical exam includes vital signs, especially pulse, respiratory rate, and blood pressure. Stressing the importance of pain assessment, the American Pain Society has coined the phrase, “Pain: the 5th vital sign.” Studies have shown a correlation between pain and changes in vital signs, but even in acute pain the vital signs are not necessarily abnormal. Tousignant-Laflamme et al demonstrated an increase in resting heart rate with acutely painful stimuli. 60 However, it is important to note that the upper limit of the 95% confidence intervals for patient’s heart rates even at the height of acute pain in this study were still less than 100 bpm (beats per minute). While there is typically a rise in heart rate with pain, the values need not be abnormal. Selfreport should therefore be considered more indicative of the presence of pain. However, observation of a patient’s response to pain (i.e., facial expression, guarding) may be all you have to go on in a pre-verbal or cognitively impaired patient.
The extent of the physical exam depends on the type of pain; pain in an extremity directly related to an injury requires a limited exam while a patient with a nonspecific complaint of pain may require a comprehensive, systematic exam. Patients with a complaint of headache require a meticulous exam of cranial nerves II, III, IV, and VI; consideration should also be given to examining the temporal artery and assessing for vertebral or carotid dissection. A complaint of chest pain requires a careful assessment of the pulses, heart, and lungs specifically looking for evidence of pneumothorax, pulmonary embolus, pneumonia, pericarditis, and aortic dissection; a careful skin exam should be done looking for evidence of herpes zoster. The differential diagnosis of abdominal pain is extensive and the clinician must carefully perform a comprehensive evaluation in order not to miss diagnostic findings. A complaint of back pain requires a full neurologic evaluation with a focus on bowel and bladder function, motor, sensory, and reflexes.
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