Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal Of The Literature
5. Pathophysiology
6. Prehospital Care
7. Emergency Department Evaluation
8. Diagnostic Studies
9. Treatment
   1. Systemic Analgesia
      1. Agents For Systemic Analgesia
         • Opioid Analgesics
      2. Non-Opioid Analgesics
      3. Dissociatives
      4. Alpha-2 Agonists
      5. Butyrophenones
      6. Route Of Administration
      7. Frequency Of Dosing
      8. Topical Anesthesia/Analgesia
      9. Regional Anesthesia
      10. Agents For Regional Anesthesia
          • Additives For Regional Anesthesia
      11. Local Infiltration
      12. Intravenous Regional Anesthesia (Bier Block)
      13. Regional Nerve Blocks
          • Digital Block
      14. Femoral Nerve Block
          • Upper Extremity Anesthesia
          • Interscalene Brachial Plexus Block
          • Intercostal Nerve Block
          • Dental Anesthesia
10. Nonpharmacologic Pain Management
11. Special Circumstances
    1. The Unconscious Or Critically Ill Patient
    2. Traumatic Abdominal Pain
    3. Pediatric Patients
    4. Geriatric Patients
    5. Narcotic-Seeking Behavior
    6. Patients With Chronic Pain
12. Disposition
13. Summary
14. Risk Management Pitfalls For Pain Management
15. Clinical Pathway For Management Of Pain In The Emergency Department
16. Time- And Cost-Effective Strategies In Pain Management
17. This Month In EM Practice Guidelines Update
18. Case Conclusions
19. Correction
20. Tables and Figures
    1. Table 1. Selected Opioid Analgesic Agents
    2. Table 2. Nonopioid Analgesic Agents And NSAIDs
    3. Table 3. Analgesic Routes Of Administration
    4. Table 4. Selected Topical And Local Anesthetic Agents
    5. Table 5. Nerves And Anatomical Areas Amenable To Regional Nerve Blocks
    6. Figure 1. Pathophysiology Of Pain
    7. Figure 2. Hematoma Block
    8. Figure 3. Bier Block
    9. Figure 4. Digital Block
    10. Figure 5. Flexor Tendon Sheath Block
    11. Figure 6. Femoral Nerve Block
    12. Figure 7. Interscalene Brachial Plexus Block
    13. Figure 8. Intercostal Nerve Block
    14. Figure 9. Apical Periosteal Block
    15. Figure 10. Inferior Alveolar Nerve Block
21. References

Abstract

Painful traumatic injuries account for a large portion of emergency department visits. Injuries may occur through various mechanisms, and many patient and provider factors affect the success of treatment. Not all injuries or patients should be treated in exactly the same fashion, and an understanding of these factors is important to providing optimal care. Medications, management strategies, and methods of evaluation have been studied with varying depth and success. Regional anesthetic techniques and nonpharmacologic means can help minimize the use of systemic agents that may have unwanted side effects. Diagnostic evaluation should not detract from symptomatic treatment. This evidence-based review summarizes the pathophysiology, historical factors, diagnostic strategies, and demographics that influence the experience of pain and provides recommendations for a variety of treatment options.

Case Presentations

A 65-year-old man with a history of COPD on home oxygen presents to your busy ED with an injury to his right hand from a fall. He states that he was walking across his living room and tripped over the oxygen tubing. As he tried to catch himself on a nearby table, he felt a painful “pop” in his hand. He denies any other injuries or pain, did not hit his head, and had no loss of consciousness or vertigo. In addition to his COPD, he has a history of coronary artery disease, hypertension, and smoking. His vital signs include a normal pulse rate and normal blood pressure. He is breathing 20 times per minute, and his oxygen saturation is 93% on 2 liters of oxygen by nasal cannula (which he uses at home). He has scattered expiratory wheezing, but he appears in no distress. You notice an obvious rotational deformity with localized swelling of his right hand. The remainder of his examination is unremarkable. He is currently experiencing minimal pain at rest, but he is unable to tolerate any movement of his hand. An x-ray shows an angulated fracture of the fifth metacarpal, which will require reduction. His family is concerned about the risks of medication you might consider because of his other medical problems. You are concerned too, since the last thing you want to do is complicate this patient’s care.

As you start to discuss a plan with the patient, a 35-year-old female who was the restrained driver in a front-impact motor vehicle collision arrives. Her airbag deployed, and there was significant damage to her car. The paramedics report tachycardia to 120 beats/minute; her other vital signs are normal. Your examination reveals a young woman in pain, with a patent airway, equal breath sounds, strong distal pulses, and tenderness to palpation in her abdomen. She has a band-like ecchymosis across her chest wall and abdomen, consistent with placement of a seat belt. She is neurologically intact and is able to report that she did not hit her head or lose consciousness. She has no other tenderness or deformities. After reporting a normal fingerstick glucose and negative pregnancy test, the nurse asks you if you would like to order something for pain; the answer is yes, but you consider the risk of lowering her blood pressure or changing her exam findings, and you wonder what the safest strategy might be.

As you are finishing your evaluation, a 55-year-old woman presents after she slipped in the shower and hit her right chest against the bathtub. She has a history of chronic low back pain managed with methadone, and she tells you, “I have a really high pain tolerance.” She has no complaints of pain anywhere else, and she did not hit her head or lose consciousness. She has no vomiting or neck pain, and her back pain is unchanged from her baseline. She has no weakness, numbness, or paresthesias, and she denies bowel or bladder dysfunction. Her only complaint is pain in her right chest, which is pleuritic and reproducible with palpation. Initial vital signs are normal, and the primary and secondary survey reveal no additional abnormalities. She appears comfortable but asks you if she can have something strong for the pain.

Introduction

The International Association for the Study of Pain defines pain as, “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”¹ Pain is present in up to 70% of emergency department (ED) visits.² It has profound economic consequences, with losses estimated at $61.2 billion per year in the United States.³ Approximately 34% of ED visits are related to injuries,4 and the majority of these warrant symptomatic management. Therefore, traumatic pain management comprises a large part of emergency care.

There has been a great deal of research performed on pain, although particular areas (eg, acute headache) have more data than others. Consequently, recommendations and discussions are not evenly distributed. Indeed, pain management is such a broad topic that fellowships and entire careers are devoted to its study. Numerous studies suggest that, in general, ED pain management is inadequate.^5-9

There are many factors that influence appropriate pain management. Patient factors (type of injury, age, medical history) as well as resource availability, cost, and provider familiarity with different options create a diverse array of practice patterns. There is no obvious “correct” strategy to any particular situation, and it benefits both the patient and provider for the emergency clinician to be familiar with the underlying mechanism and treatment options for such conditions. This issue of Emergency Medicine Practice provides a foundation for the management of acute traumatic pain in the emergency setting. While not intended to be all-inclusive, it will present an evidence-based appraisal of issues related to this topic.

Critical Appraisal Of The Literature

As of June 2012, there were nearly 500,000 articles related to pain indexed in Ovid MEDLINE® and over 200 reviews in the Cochrane Database of Systematic Reviews. While this provides a plethora of information, not all of this literature is relevant to the practice of emergency medicine. A review was performed, building on previous works^10,11 and focusing on issues pertinent to traumatic pain management in the ED. Some 510 articles were identified in MEDLINE® with the search terms emergency trauma analgesia. Additional resources were used, including the Web of Science, The National Guideline Clearinghouse (www.guideline.gov), articles known to the author, and several textbooks.

Many of the seminal investigations guiding the practice of trauma analgesia were performed by anesthesiologists and surgeons prior to the advent of emergency medicine. This does not negate their utility, but, in some cases, this may limit generalizability to the ED setting.

Risk Management Pitfalls For Pain Management

1. “I thought the patient was just seeking pain medication to get high.”

   Drug-seeking behavior is a difficult problem in the ED, and it is one to which there is not a simple answer. If serious concern exists, an attempt may be made to validate the patient’s claims (eg, calling the primary provider, reviewing pharmacy dispensing records, etc), but this is often unsuccessful, and the individual solution may rest with the clinician’s judgment or departmental policy.

2. “I didn’t want to give pain medication because I didn’t want to mask the examination findings.”

   Appropriate analgesia does not compromise physical examination findings for serious injury and may, in fact, improve the ability to localize painful stimuli. This has been demonstrated reproducibly in the ED setting.

3. “The patient felt better with pain medication, so I didn’t pursue further diagnostic testing.”

   While analgesia may improve comfort, careful attention must still be paid to historical elements (eg, high-energy motor vehicle collision) or examination findings (eg, abdominal tenderness) that may be concerning for serious pathology. A focused examination after analgesia may reveal whether abnormal findings can be evoked in an otherwise comfortable patient.

4. “There was no radiographic abnormality, so I didn’t think the patient needed pain medication.”

   Pain is a subjective experience, and many causes of pain (particularly neuropathic pain) may not provide objective evidence of the level of discomfort.

5. “I didn’t consider regional anesthesia.”

   Regional anesthesia is an increasingly popular means of achieving analgesia and decreasing the amount of systemic analgesia required. It is useful to have a repertoire of familiar and useful techniques to augment some scenarios (eg, dental blocks for dental injuries, digital blocks for finger injuries, etc).

6. “The patient was agitated, and I didn’t consider pain as the etiology.”

   Many times patients are unable to communicate their discomfort adequately (eg, intubated or demented patients). Painful conditions should be considered as a cause of increased agitation or delirium.

7. “The vital signs were normal, so I decided the patient was not in pain.”

   Vital sign abnormalities are not a reliable indicator of pain. In addition to medications that may blunt a response (eg, beta-blockers), each patient’s experience and physiologic response may be different, and some patients may experience significant pain without producing abnormal vital signs.

8. “The patient had opioid dependence, so I used an agonist-antagonist.”

   Some partial agonists (eg, buprenorphine) bind with more affinity than complete agonists. In a patient on a chronic long-acting opioid agonist (eg, methadone), introduction of a partial agonist may displace complete agonists at the receptor site and precipitate a relative withdrawal.

9. “I had to keep giving him pain medication because he wouldn’t calm down.”

   Anxiolysis is an important part of pain control and limiting “wind-up” phenomenon. Often, this can be accomplished by nonpharmacologic means (eg, discussing the patient’s concern, covering a wound, distracting a child, or immobilizing a limb).

10. “The patient was fine when she left for x-ray, but when she returned, she was screaming in pain.”

    Splinting with radiolucent materials prior to transport or manipulation for imaging helps decrease the pain precipitated by mobilization. In addition, it is reasonable to provide additional analgesia in anticipation of painful procedures or transport.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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56. Kendrick DB, Strout TD. The minimum clinically significant difference in patient-assigned numeric scores for pain. Am J Emerg Med. 2005;23(7):828-832. (Prospective; 354 patients)
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59. McGrath PA, Seifert CE, Speechley KN, et al. A new analogue scale for assessing children’s pain: an initial validation study. Pain. 1996;64(3):435-443. (Comparison; 104 patients)
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61. Warden V, Hurley A, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc. 2003;4(1)4:9-15. (Prospective; 19 patients)
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72. McGuinness SK, Wasiak J, Cleland H, et al. A systematic review of ketamine as an analgesic agent in adult burn injuries. Pain Med. 2011;12(10):1551-1558. (Systematic review)
73. Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med. 2008;26(9):985-1028. (Systematic review)
74. Bisanzo M, Nichols K, Hammerstedt H, et al. Nurse-administered ketamine sedation in an emergency department in rural Uganda. Ann Emerg Med. 2012;59(4):268-275. (Observational; 191 patients)
75. Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006;18(1):37-44. (Systematic review)
76. Albanese J, Arnaud S, Rey M, et al. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology. 1997;87(6):1328-1334. (Prospective; 8 patients)
77. Schmidt A, Oye I, Akeson J. Racemic, S(+)- and R(-)-ketamine do not increase elevated intracranial pressure. Acta Anaesthesiol Scand. 2008;52(8):1124-1130. (Clinical trial; 9 pigs)
78. Bar-Joseph G, Guilburd Y, Tamir A, et al. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009;4(1):40-46. (Prospective controlled; 30 patients)
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81. Bourgoin A, Albanese J, Leone M, et al. Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients. Crit Care Med. 2005;33(5):1109-1113. (Prospective randomized; 30 patients)
82. Gerlach AT, Murphy CV, Dasta JF. An updated focused review of dexmedetomidine in adults. Ann Pharmacother. 2009;43(12):2064-2074. (Systematic review)
83. Richards JR, Richards IN, Ozery G, et al. Droperidol analgesia for opioid-tolerant patients. J Emerg Med. 2011;41(4):389-396. (Review)
84. Sharma SK, Davies MW. Patient-controlled analgesia with a mixture of morphine and droperidol. Br J Anaesth. 1993;71(3):435-436. (Prospective randomized; 50 patients)
85. Lo Y, Chia YY, Liu K, et al. Morphine sparing with droperidol in patient-controlled analgesia. J Clin Anesth. 2005;17(4):271-275. (Randomized double-blind; 179 patients)
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87. Yamamoto S, Yamaguchi H, Sakaguchi M, et al. Preoperative droperidol improved postoperative pain relief in patients undergoing rotator-cuff repair during general anesthesia using intravenous morphine. J Clin Anesth. 2003;15(7):525-529. (Prospective randomized double-blind; 84 patients)
88. Kao LW, Kirk MA, Evers SJ, et al. Droperidol, QT prolongation, and sudden death: what is the evidence? Ann Emerg Med. 2003;41(4):546-558. (Systematic review)
89. Nuttall GA, Eckerman KM, Jacob KA, et al. Does low-dose droperidol administration increase the risk of drug-induced QT prolongation and torsade de pointes in the general surgical population? Anesthesiology. 2007;107(4):531-536. (Retrospective; 4528 patients)
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