Acute Pain Management

Pain
Pain is an unpleasant feeling that is
conveyed to the brain by sensory
neurons as a result of injury, disease or
emotional disorder

Pain
Acute pain
Less than six months duration
Cause is usually known
Disappears when the injury heals
Chronic pain
More than six months durations
Persists after injury heals
Cause may or may not be known


IASP website, 2007
Types of pain
Neuropathic (burning, tingling, pins and
needles sensation)
Psychogenic
Idiopathic
Common types of acute pain
Type or source Definition Examples
Acute illness Pain associated with an
acute illness
Appendicitis, renal colic,
myocardial infarction
Prioperative (includes
postoperative)
Pain in a surgical
patient because of pre-
existing disease,
surgical procedure,
associated drains, chest
or NG tube
Head or neck surgery,
chest and chest wall,
abdominal, orthopedic
surgery
Post traumatic (major
trauma)
Generalised or
regionalised pain due to
major acute injury
Motor vehicle accident
Common types of acute pain
Type or source Definition Example
Post traumatic (minor
injury)
Pain due to minor injury Sprain, laceration
Burns Pains due to thermal or
chemical burns
Fire, chemical exposure
Procedural Pain associated with a
diagnostic or
therapeutic medical
procedure
Bone marrow biopsy,
endoscopy, suturing
catheter and chest tube
placement,circumcision,
immunization
Obstetrical Pain related to labour
and delivery
Child birth by vaginal
delivery or cesarean
section
Pain pathways
Tissue injury activate nociceptors pain
impulse A-delta & C fibers dorsal horn
spinothalamic tract thalamus
cerebral cortex cerebellum
Mediators
Prostaglandin, bradykinin, substance P,
serotanin, histamine





Physiological effects of pain
Cardiovascular effects
Increased heart rate
Hypertension
Myocardial irritability
Increased oxygen demand
Respiratory effects
Increased O
2
consumption
Increased CO
2
production
Increased work of
breathing
Decreased movement of
chest
hypoxaemia
Gastrointestinal effects
Increased sphincter tone
Increased GI secretion
Nausea, vomiting

Physiological effects of pain
Endocrine effects
Increased catabolic
hormones (glucagon, GH,
vasopressin )
Decreased anabolic
hormones (insulin,
testosterone)

Haematologic effects
Increased platelet
adhesiveness
hyper coagulability

Immune effects
Lymphopaenia
Leukocytosis


Musculo skeletal
muscle spasm, immobility,
increased risk of DVT
muscle wasting, prolonged
recovery
CNS
central sensitization,
chronic pain
Psychological
Anxiety, fear, sleep
deprivation, increased pain
Urinary effects
Urinary retention
Non pharmacological
Transcutaneous nerve stimulation
Cognitive and behavioral therapy
Heat and cold
Physical and occupation therapy
Rehabilitation
Progressive muscle relaxation
Psychotherapy
Massage, accupuncture and accupressure
Exercise therapy
Lifestyle changes

Multimodal analgesia
Drugs
Reduce doses of each analgesic
Synergistic / additive effects
Decrease severity of side effects of each
drug
Technique
Oral, I/M, I/V, S/C, per rectal, nerve block,
plexus block, epidural block


Treatment
Pharmacologic
Opioid

Non opioid

Adjuvant
Pain management guideline
Pain symptom
intensity
Drug selection
Constant moderate to
severe pain
Intermittent pain
Long acting analgesics +prn
short acting analgesics
prn short acting
analgesics
Mild
Moderate
severe
Multimodal analgesia
Non opioids
Acetaminophen
Local anesthetic drugs
Nonsteroidal anti-inflammatory drugs
steroids

No physical dependence
No tolerance


Acetaminophen
Effective analgesic
Action
Analgesic
Antipyretic
Anti-inflammatory agent
Relative safety
Effective for the musculoskeletal aches,
joint stiffness
Acetaminophen
Disadvantage
Dose-dependent hepatotoxicity, GI upset
Agranulocytosis
Dosage
650-1000 mg PO q 4 hr.
Max. 4 g/d
Reduce dose 50-70% in patient with
significant hepatic impairment

NSAID
Drug Dosage Maximum daily
dose
Nonselective
inhibitor
Diclofenac
Indomethacin
Ibuprofen


50 mg PO bid-tid
75 mg PO bid
200-800 mg q 6
hr.


200 mg
150 mg
3200 mg
Cox-2 inhibitor
Celecoxib

100-200 mg PO
bid

400 mg
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