Pain & Sedation
A 19 year old woman presents to the Emergency Department after inverting her ankle on an escalator. She has no significant past medical history and has no allergies. In triage she scores her pain as 3/10, she has not yet taken any analgesia. Which of the following analgesics plans is the most appropriate?
Answer:
| No Pain (0) | Mild Pain (1-3) | Moderate Pain (4-6) | Severe Pain (7-10) | |
|---|---|---|---|---|
| Analgesia | No action | Oral paracetamol OR oral NSAID | As for mild pain, PLUS oral NSAID (if not already given) OR oral codeine phosphate | IV opiates OR rectal NSAIDs PLUS oral analgesics |
| Initial assessment | Within 15 minutes of arrival | Within 15 minutes of arrival | Within 15 minutes of arrival | Within 15 minutes of arrival |
| Review | Within 60 minutes of initial assessment | Within 60 minutes of initial assessment | Within 30 minutes of initial assessment | Within 15 minutes of initial assessment |
Pain Management
Pain & Sedation
Last Updated: 15th December 2022
Recognition and alleviation of pain should be a priority when treating the ill and injured. This process should start at triage, be monitored during their time in the ED and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge.
When patients first present to the ED the diagnosis may be unclear and it is important that the lack of diagnosis does not delay administration of appropriate analgesia. It is recognised however that there are a number of conditions or presentations in which certain types or combinations analgesics are known to perform particularly well e.g. angina and nitrates. All emergency departments should ensure patients with moderate and severe pain receive adequate analgesia within 15 minutes of arrival.
Types of analgesia
- Paracetamol
- Available as oral, rectal and intravenous preparations
- Standard oral and IV dose for adults is 1 g qds (IV dose adjusted for patients < 50 kg)
- IV route is particularly useful when patients need to be kept nil by mouth and rapid mild-moderate analgesia is required
- Rectal preparation is probably best avoided due to variable and slow absorption in adults
- Before prescribing paracetamol inquiry must be made regarding previous paracetamol use prior to arrival in ED
- NSAIDs
- Available as oral, rectal, intravenous and intramuscular preparations
- Ibuprofen
- Ibuprofen 400 mg PO tds
- Fewer side effects than other NSAIDs, good analgesic but relatively weak anti-inflammatory properties
- Naproxen
- Naproxen 500mg PO initially then 250 mg every 6-8 hrs in acute musculoskeletal disorders
- Stronger anti-inflammatory properties than ibuprofen but with relatively fewer side-effects compared to other NSAIDs
- Diclofenac
- Diclofenac 50 mg PO tds, 100mg PR
- Particularly useful for the treatment of renal colic pain via the rectal route however in recent years concern has been raised regarding increased risk of thrombotic events (incl. MI) and Clostridium difficile and it is contraindicated in IHD, PVD, CVD and heart failure
- Avoid NSAIDS in asthmatics who are known to get worsening bronchospasm with NSAIDS, also avoid in patients with previous or known peptic ulcer disease
- NSAIDs should be used with caution in the elderly (risk of peptic ulcer disease) and women who are experiencing fertility issues
- NSAIDs should also be avoided in pregnancy, particularly during the third trimester
- Opiates
- Codeine
- Available as oral and IM preparations
- 30-60 mg qds are typical adult doses however consider lower doses in the elderly
- Codeine prescribed in combination with paracetamol is significantly more effective than codeine when prescribed alone
- Morphine
- Available as oral, intravenous and intramuscular preparations (due to its relatively slow onset of action the oral preparation is not recommended for acute pain control in the ED, unless the patient is already taking the drug in which case this might be a reasonable alternative)
- Morphine 0.1-0.2mg/kg IV is a typical adult dose, however a titrated dose to provide the desired response is recommended; consider lower doses in the elderly
- Use opiates with caution if risk of depression of airway, breathing or circulation
- The routine prescription of an antiemetic with an opiate is not recommended, and only required if patient is already experiencing nausea / vomiting
- Codeine
- Entonox
- Entonox, a 50% mixture of nitrous oxide and oxygen, is very useful for short term relief of severe pain and for performing short lasting uncomfortable procedures
- Entonox should not be viewed as a definitive analgesic and EDs need mechanisms in place to ensure rapid assessment and institution of appropriate analgesia when paramedics bring patients to the ED who are using Entonox as their sole source of analgesia.
- Entonox should be avoided in patients with head injuries, chest injuries, suspected bowel obstruction, middle ear disease, early pregnancy and B12 or folate deficiency
Pain assessment
Pain assessment forms an integral part of the National Triage Scale. Multiple assessment tools are in use. The better known scales have not been validated in the context of an ED environment but are nevertheless satisfactory for the purpose of pain assessment and management. The experience of the member of staff triaging will help in estimating the severity of the pain.
The literature suggests that assessment of pain in the ED is often not as good as it could be which is particularly concerning since pain is often the reason for attending, patient assessment is improved by giving adequate analgesia, painful or uncomfortable procedures may be undertaken in the ED and there are clear physiological benefits to providing adequate analgesia.
Documentation of analgesia is essential and departments are encouraged to formalise pain recording in the same manner as the regular documentation of vital signs.
Pain management
| No Pain (0) | Mild Pain (1-3) | Moderate Pain (4-6) | Severe Pain (7-10) | |
|---|---|---|---|---|
| Analgesia | No action | Oral paracetamol OR oral NSAID | As for mild pain, PLUS oral NSAID (if not already given) OR oral codeine phosphate | IV opiates OR rectal NSAIDs PLUS oral analgesics |
| Initial assessment | Within 15 minutes of arrival | Within 15 minutes of arrival | Within 15 minutes of arrival | Within 15 minutes of arrival |
| Review | Within 60 minutes of initial assessment | Within 60 minutes of initial assessment | Within 30 minutes of initial assessment | Within 15 minutes of initial assessment |
In all cases it is important to think of using other non-pharmacological techniques to achieve analgesia, which may include measures such as applying a dressing or immobilising a limb etc. Following reassessment if analgesia is still found to be inadequate, stronger / increased dose of analgesics should be used along with the use of non-pharmacological measures.
When prescribing for the elderly it is worth remembering that paracetamol (including intravenous) is a safe first line treatment with a good safety profile. NSAIDS should be used with caution and at the lowest possible dose in older adults in view of gastrointestinal, renal and cardiovascular side effects as well as drug-drug interactions and the effects on other comorbidities. When using opiate medication in the elderly appropriate dose reduction should be used as well as anticipating any other drug interactions; particularly those acting on the central nervous system which may increase the likelihood of respiratory depression.
When prescribing in pregnancy the general rule is try to avoid any medication, however this is not always practical. Paracetamol is considered safe in all three trimesters, ibuprofen is best avoided and can only be used during the second trimester (if essential). Morphine and codeine can be used in all three trimesters if necessary but should be avoided during delivery.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
