Pain in the Emergency Department

dr. Prabowo Wicaksono Y.P., SpAn

KMN M.Biomed
Introduction
• Pain is the single most common reason for
presentation to emergency departments (ED).
• Accounts for up to 78% of visits to the ED.
• Causes: medical and surgical.
• Severity: mild to very severe.
• Prevalence: there is strong evidence that patients in
ED around the world receive suboptimal pain
management (“oligoanalgesia”).
• Some evidence that ED patients may be different
from other patients: they may have already tried
self-medication before coming to the ED.
ORIGINAL REPORTS

Pain in the Emergency Department: Results of the Pain and

Emergency Medicine Initiative (PEMI) Multicenter Study
Knox H. Todd,* James Ducharme,† Manon Choiniere,‡ Cameron S. Crandall,§
David E. Fosnocht, Peter Homel,¶ and Paula Tanabe,** for the PEMI Study Group

*Pain and Emergency Medicine Institute, Beth Israel Medical Center, New York, New York.
†Department of Emergency Medicine, Atlantic Health Sciences Corporation, St. John, New Brunswick, Canada.
‡Department of Anesthesiology, Faculty of Medicine, University of Montreal, Montreal, Canada.
§Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.
Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
¶Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York.
**Department of Emergency Medicine, Northwestern School of Medicine, Chicago, Illinois.

Perspective:
Despite the frequency of pain in the emergency department, few studies have
examined this phenomenon. This study documents high pain intensity and
suboptimal pain management practices in a large multicenter ED network in
the United States and Canada. These findings suggest that there is much room
for improvement in this area.
J Pain. 2007; 8 (6): 460-66.
Introduction
• Pain is the single most common reason for
presentation to emergency departments (ED).
• Accounts for up to 78%of visits to the ED.
• Causes: medical and surgical.
• Severity: mild to very severe.
• Prevalence: there is strong evidence that patients in
ED around the world receive suboptimal pain
management (“oligoanalgesia”).
• Some evidence that ED patients may be different
from other patients: they may have already tried
self-medication before coming to the ED.
ORIGINAL REPORTS

Pain in the Emergency Department: Results of the Pain and

Emergency Medicine Initiative (PEMI) Multicenter Study
Knox H. Todd,* James Ducharme,† Manon Choiniere,‡ Cameron S. Crandall,§
David E. Fosnocht, Peter Homel,¶ and Paula Tanabe,** for the PEMI Study Group

*Pain and Emergency Medicine Institute, Beth Israel Medical Center, New York, New York.
†Department of Emergency Medicine, Atlantic Health Sciences Corporation, St. John, New Brunswick, Canada.
‡Department of Anesthesiology, Faculty of Medicine, University of Montreal, Montreal, Canada.
§Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.
Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
¶Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York.
**Department of Emergency Medicine, Northwestern School of Medicine, Chicago, Illinois.

Perspective:
Despite the frequency of pain in the emergency department, few studies
have examined this phenomenon. This study documents high pain intensity
and suboptimal pain management practices in a large multicenter ED
network in the United States and Canada. These findings suggest that there
is much room for improvement in this area.
J Pain. 2007; 8 (6): 460-66.
 Table. Major categories of discharge diagnoses.
N (%)
- Wound, abrasion or contusion 91 (11)
- Sprain or strain 90 (11)
- Back or neck pain 85 (10)
- Abdominal pain 71 (9)
- Fracture or dislocation 48 (6)
- Headache 47 (6)
- Chest pain (noncardiac) 40 (5)
- Upper respiratory infection 30 (4)
- Abscess or cellulitis 25 (3)
- Toothache 19 (2)
- Urinary tract infection 16 (2)
- Renal colic 14 (2)
- Other diagnoses 243 (30)
- Total with ICD-9 diagnosis 819 (100)

Todd KH et al. J Pain. 2007; 8 (6): 460-66.

Figure. Pain intensity at ED arrival and discharge.
Todd KH et al. J Pain. 2007; 8 (6): 460-66.
Original article SWISS MED WKLY 2010; 14 0 (23-24): 341-47.

Pain in the emergency department: adherence to an

implemented treatment protocol
Frank-Peter Stephana*, Christian H. Nickela*, Jaqueline S. Martinb, Daniela Grethera,
Karen Delport-Lehnena, Roland Bingissera
a Department of Emergency Medicine, University Hospital, Basel, Switzerland
b Department of Clinical Nursing Science, University Hospital, Basel, Switzerland

Summary
Objectives:
Although pain is one of the most common presenting complaints in the Emergency
Department (ED), pain management is often inadequate. Pain management
protocols have been shown to be useful. The objective of this study was to assess
the adherence to an already implemented pain management protocol in an urban
ED.
Methods:
Secondary analysis of a prospective single centre cohort study on patient
preferences for analgesia in the ED. Patient charts were reviewed with a focus on
selection, timing and dosage of analgesics according to a visual analogue scale (VAS)
on arrival and during the ED stay.
Original article SWISS MED WKLY 2010; 14 0 (23-24): 341-47.

Pain in the emergency department: adherence to an

implemented treatment protocol
Frank-Peter Stephana*, Christian H. Nickela*, Jaqueline S. Martinb, Daniela Grethera,
Karen Delport-Lehnena, Roland Bingissera
a Department of Emergency Medicine, University Hospital, Basel, Switzerland
b Department of Clinical Nursing Science, University Hospital, Basel, Switzerland

Summary
Results:
Three hundred and thirty-seven patient charts were reviewed. The adherence to the
implemented pain management protocol was 42% at the time of initial evaluation
and 43% during the course of therapy in all patients. Forty-two percent of the study
population were discharged with at least moderate pain. However, 43% of the
patients discharged with pain did not request analgesics.
Conclusions:
The benefits of pain management protocols are proven. However, adherence to
these protocols needs to be monitored regularly in order to optimise pain
management.
Keywords: pain management; treatment protocol; emergency department; opiophobia
PRINCIPLES
Choice of Analgesia:
• Should be the simplest, most condition-
specific, and most local that is effective.
• Patient suffering myocardial ischemia, an appropriate initial
analgesic is nitroglycerin, although it has no intrinsic analgesic
properties.
• Patient with a crushed digit, although NO or systemic opioid
may be needed in the short term, a digital nerve block is
highly effective ongoing analgesia and may additionally
facilitate wound repair
• Patient suffering pain due to an envenomation, treatment of
the envenomation rather than, or concurrent with, systemic
analgesia is indicated.
PRINCIPLES
Systems for Analgesia Delivery:
A system to deliver timely and effective
analgesia requires the following elements:
• a process to quantify and document pain at
regular intervals (e.g. using pain scores),
• a process to initiate appropriate therapy, and
• a process to monitor response to initial
therapy and provide additional analgesia as
required
Examples of system design to achieve this :
• assessment of pain intensity at the time of triage and
integrating it as part of the assignment of triage (treatment
priority) categories
• development of pain management guidelines to direct choice
of agent, and
• route of administration for selected conditions.

Analgesia can be initiated at the time of triage for patients who

are expected to have to wait before medical treatment:
• may take the form of topical anesthesia for a wound or oral
medication.
• for patients suffering severe pain, a titrated i.v. opioid
protocol can be effective, as can nurse-initiated titrated i.v.
opioids for selected conditions.
Analgesia at the Extremes of Age
• Children and the elderly receive poorer pain
management in ED than adults.
• Reasons for this are unclear and probably multi-
factorial.
• There appears to be reluctance to treat children with
parenteral analgesics and/or to delay i.v. insertion for
analgesia until topical anesthetic has been employed.
• Children suffering severe pain should receive
appropriate analgesia without delay.
Analgesia at the Extremes of Age
• Elderly, some concerns appear to be centered
on the risks of sedation and hypotension.
• Although physiological changes make
responses to analgesia different in the elderly,
this is insufficient justification for under-
analgesia.
• Ideally served by titrated doses of opioids as
described under systemic analgesia.
SYSTEMIC ANALGESIA IN ED
• Opioids
• Tramadol
• Nonsteroidal Anti-Inflammatory Drugs
• Nitrous oxide
• Ketamine
ANALGESIA FOR SPECIFIC CONDITIONS
Abdominal pain:
• Abdominal pain is severe, opioids are often required.
• Previously been recommended that pethidine be used
in preference to morphine, particularly for renal and
biliary colic due to the theoretical risk of spasm, there
is no evidence to support this position
• A meta-analysis of prospective trials of ED patients
with abdominal pain receiving opioid analgesia found
that there were no adverse outcomes or diagnostic
delays in patients who received analgesia.
ANALGESIA FOR SPECIFIC CONDITIONS
Renal colic:
• Usually present to ED with severe pain.
• Often distressed and require rapidly administered
analgesia.
• Most of the evidence regarding the ED management of
• Renal colic examines the use of opioid analgesics, NSAIDs,
or both.
• Ketorolac 30 mg i.m. was reported to be as effective as
pethidine 100 mg i.m., with no difference in the proportion
of patients improving at one hour between groups.
• Titrated i.v. opioids have traditionally been the mainstay of
treatment and provide rapid analgesia.
ANALGESIA FOR SPECIFIC CONDITIONS
Biliary colic:
• Patients with biliary colic often report severe pain.
• The choices for analgesia are opioids, NSAIDs, anti-
cholinergic medications, or a combination of these.
• Patients with severe pain or who are vomiting should
be treated with parenteral opioids.
• Pethidine has been the analgesic of choice for biliary
colic, based on the belief that morphine may increase
pain by causing contraction/spasm of the sphincter of
Oddi, whereas pethidine does not have this effect.
• There are no data directly comparing the effectiveness
and side effects of these agents, so neither can be
recommended above the other.
ANALGESIA FOR SPECIFIC CONDITIONS
Biliary colic:
• Ketorolac 60 mg i.m. has been found to be as
effective as i.m. pethidine (1.5 mg/kg up to 100 mg).
• Ketorolac 30 mg i.v was found to provide similar
analgesia at 30 min, one and two hours to pethidine
50 mg i.v. with a lower incidence of nausea.
• NSAIDs require at least 15–30 minutes for
• Onset of analgesia even if given parenterally, for
severe pain, it is appropriate to use titrated i.v.
opioids initially followed by NSAIDs.
ANALGESIA FOR SPECIFIC CONDITIONS
Biliary colic:
• Anticholinergic drugs are of little benefit in the ED
management of biliary colic.
• Glycopyrrolate showed no benefit over placebo.
• Hyoscine-N-butylbromide, long a favored treatment
for biliary colic, gave less pain relief when compared
with NSAIDs.
• The onset of action of hyoscine-N-butylbromide was
also slower and there were more recurrent episodes
of pain in patients given hyoscine-N-butylbromide.
ANALGESIA FOR SPECIFIC CONDITIONS
Ischemic cardiac chest pain:
• Initial treatment for suspected ischemic cardiac chest
pain should be with aspirin (as an anti-platelet agent,
rather than an analgesic) and nitroglycerin, usually
administered sublingually.
• Pain persist or hypotension, potential interactions (e.g.
with sildenafil), or other adverse effects limit
nitroglycerin use, i.v. morphine titrated to effect is
recommended.
• Nitroglycerin or diltiazem administered as i.v. infusions
are options if pain is difficult to control.
• Intravenous nitroglycerin, at infusion rates of 5–50
mg/min, has been reported to reduce episodes of chest
pain in patients with clinical unstable angina when
compared to placebo
ANALGESIA FOR SPECIFIC CONDITIONS
Ischemic cardiac chest pain:
• Intravenous diltiazem, at a dose titrated to effect of
between 1 and 5 mg/kg per minute, has been reported
to be effective in 94 percent of patients with few side
effects.
• When compared to intravenous nitroglycerin in small
studies, intravenous diltiazem is reported to result in less
refractory angina than intravenous nitroglycerin.
• Beta-blockers may have a place in selected patients who
do not achieve control of chest pain with the above
agents.
ANALGESIA FOR SPECIFIC CONDITIONS
Ischemic cardiac chest pain:
• Cohort studies of esmolol and metoprolol infusions have
reported reduction in pain intensity and frequency.
• When compared to titrated i.v. morphine, both treatments
resulted in significant reductions in pain, but morphine was
effective faster.
• Indicative doses of esmolol: 2–24mg/min titrated to reduce
the HR and SBP product by 20–25 percent.
• Indicative doses of metoprolol: 2.5–5mg every five to ten
minutes as intermittent boluses or 3 mg/min as an infusion
titrated to heart rate, blood pressure, and effect.
• Beta-blockage is contraindicated in patients with bradycardia,
advanced atrioventricular block, hypotension, significant
pulmonary congestion, or severe chronic obstructive airways
disease.
ANALGESIA FOR SPECIFIC CONDITIONS
Migraine:
• Mild to moderate migraine without nausea and vomiting in
patients who have not tried an anti-migraine agent for this
episode: aspirin in a dose of 1000 mg or the combination of
aspirin 600 mg and metoclopramide 10 mg orally may be
effective.
• Acetaminophen has not been shown to be superior to
placebo.
• Severe migraine, the evidence suggests that the most
effective agents: triptans (sumatriptan and related agents)
and phenothiazines (chlorpromazine and prochlorperazine).
• Metoclopramide and ketorolac are also commonly used.
• Opioids are not indicated for the treatment of migraine,
despite being commonly used in some countries.
ANALGESIA FOR SPECIFIC CONDITIONS
Fractured neck of the femur:
• Australian study: only 49 percent of patients with
fractured neck of femur received analgesia in the ED and
that the median delay was 2.75 hours.
• US study: patients with fractured neck of the femur were
less likely than other lower extremity fractures to receive
analgesia in the prehospital setting (11 versus 32%).
• Early ED phase: titrated i.v. morphine is appropriate to
gain initial pain control.
• Available evidence suggests that femoral nerve or
‘‘three-in-one’’ local anesthetic blocks can provide good
analgesia for patients who have had surgery for fractures
of the femoral neck.
ANALGESIA FOR SPECIFIC CONDITIONS
Fractured neck of the femur:
Fletcher et al.:
• Compared ‘‘three-in-one’’ femoral nerve block using
bupivacaine plus i.v. morphine with i.v. morphine
alone.
• Combination had a faster time to analgesia and
lower morphine requirements in the first 24 hours.
ANALGESIA FOR SPECIFIC CONDITIONS
Wound:
• Local anesthesia is often required for the treatment of
wounds.
• Two routes of administration are in common use in the
ED: local infiltration and topical application.
• Regional nerve blocks may also be appropriate in
selected cases.
• Topical anesthetic preparations such as ALA (epinephrine
(adrenaline), lidocaine, amethocaine) have been shown
to be effective alternatives to infiltration of local
anesthesia for selected simple lacerations.
• In patients with sensitivity to local anesthetic agents,
infiltration of diphenhydramine may provide adequate
analgesia.
ANALGESIA FOR SPECIFIC CONDITIONS
Analgesia for fracture and dislocation reduction:
• Analgesia for the management of limb fractures and
dislocations in the ED requires both pharmacological and
nonpharmacological treatments.
• Nonpharmacological methods : splinting, traction devices,
elevation, and mobility assistance devices, such as crutches
for lower limb injuries.
• Initial pain management for patients with fractures or
dislocations causing significant pain should be with titrated i.v.
opioids.
• Pharmacological treatment for reduction of fractures and
dislocations in the ED usually requires sedation or anesthesia
(local or regional), in addition to analgesia.
ANALGESIA FOR SPECIFIC CONDITIONS
Analgesia for fracture and dislocation reduction:
• Morphine, fentanyl, and pethidine are the opioids most
commonly used in conscious sedation for fracture reduction .
• Soysal et al.: equal effectiveness of pethidine and fentanyl
when combined with midazolam in adult fracture reduction.
• Ketorolac, when added to a midazolam/fentanyl combination,
did not result in significant additional analgesia nor did it
provide significant opioid sparing.
ANALGESIA FOR SPECIFIC CONDITIONS
Analgesia for fracture and dislocation reduction:
• Ketamine, has been used as an alternative to opioid analgesia
in fracture reduction in children.
• It has the advantage of being able to be administered i.v. or
i.m. with usual initial doses 4mg/kg for i.m. administration
and 0.5–1mg/kg for i.v. administration.
• Combination of ketamine and midazolam is safer than
fentanyl and midazolam in pediatric fracture and dislocation
reduction, resulting in fewer respiratory complications, such
as hypoxia.
• Disadvantages to ketamine were an increased incidence of
vomiting and a longer recovery time.
ANALGESIA FOR SPECIFIC CONDITIONS
Analgesia for fracture and dislocation reduction:

• Propofol has also been used in combination with opioids, in

particular fentanyl, as analgesia/sedation for fracture
reduction in both children and adults.

• A recent systematic review comparing propofol/fentanyl with

ketamine/midazolam and fentanyl/midazolam concluded that
ketamine/midazolam seemed to be more effective and have
fewer adverse events than the other combinations.
ANALGESIA FOR SPECIFIC CONDITIONS
Forearm fractures:
• Hematoma block: reduction of both wrist and ankle fractures,
injection of local anesthetic into the hematoma associated
with the fracture.
• In comparison with conscious sedation without anesthesia, it
has been reported that patients who underwent a hematoma
block for fracture reduction had greater pain score reductions.
• Similar effectiveness to a ketamine/midazolam combination
was reported when hematoma block was combined with
nitrous oxide in children.
ANALGESIA FOR SPECIFIC CONDITIONS
Forearm fractures:
• IVRA (Bier’s block) is an alternative method of anesthesia for
forearm fracture reduction. It is relatively simple to perform,
is low risk, has a rapid onset of action, rapid recovery, and
does not depress conscious level and hence risk airway
compromise.
• IVRA has been reported to be very effective as analgesia for
reduction of wrist fractures and forearm fractures.
• Recent Cochrane review: when compared with hematoma
block, IVRA provided better analgesia during fracture
manipulation and enabled better and easier reduction of the
fracture with a trend towards reduced risk of later
redislocation or need for rereduction.
ANALGESIA FOR SPECIFIC CONDITIONS
Forearm fractures:
• Nerve blocks have been reported as being effective for the ED
treatment of forearm fractures in both children and adults.
• These include axillary blocks129[III] and combined median,
ulnar, and radial nerve blocks at the elbow.
• These also require training and experience in order to achieve
acceptable success rates.
ANALGESIA FOR SPECIFIC CONDITIONS
Shoulder dislocation:
• Conscious sedation is the most common analgesia used for
the reduction of shoulder dislocations.
• 2 randomized trials reporting on the effectiveness of intra-
articular lidocaine in this context:
- Typically, 20mL of 1 percent lidocaine is used.
- Both studies report no difference in pain scores or
procedural success when comparing intraarticular
anesthesia to i.v. conscious sedation.
KEYPOINTS:
• Pain management in emergency departments (ED)
requires a system for quantification of pain, initiation
of therapy, and reassessment.

• As a general rule, the approach to analgesia in EDs

should be simple before complex, specific before
nonspecific, and local before general.

• When opioids are required for severe pain,

parenteral administration is usually indicated in the
initial phases of ED care and the intravenous (i.v.)
route is preferred when practical.
KEYPOINTS:
• Opioid-tolerant patients are likely to require higher
doses of opioid in order to achieve analgesia. Opioids
should not be withheld from any patient where there
is an apparently genuine cause for pain.

• Ketamine may be a useful adjunct to i.v. opioids in

patients who are requiring high doses of opioids in
very painful conditions, such as severe burns.