EMERGENCY SEDATION AND PAIN MANAGEMENT - PART 4 pps

12. Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: What does the literature say? [In process citation]. Acad Emerg Med 2000;7(6):695–709. 13. Yarnold PR, et al. Predicting patient satisfaction: A study of two emergency departments. J Behav Med 1998;21 (6):545–563. 14. Larsen MJ, Fosnocht DE, Swanson ER. Pain management after discharge from the emergency department. Ann Emerg Med 2004;44(4):S88. 15. Todd KH. Pain and pain-related functional interference among discharged emergency department patients. Ann Emerg Med 2004;44(4):s86. 78 Analgesia for the Emergency Patient 12 Analgesia for the Adult and Pediatric Multitrauma Patient Wayne Triner SCOPE OF THE PROBLEM CLINICAL ASSESSMENT OF PAIN AND MANAGEMENT OF THE MULTITRAUMA PATIENT PAIN/SEDATION CONSIDERATIONS PAIN AND SEDATION MANAGEMENT Nonpharmacological Approaches to Analgesia Strategies in the Provision of Analgesic and Sedative Agents Regional and Local Anesthesia SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM Multiple trauma is defined as injury to two or more organ systems. Without exception, pain is a major consideration in the management of the patient with multiple injuries. Yet, the often-competing physiological and operational demands associated with these patients increase the complexity as well as the risk of meeting their analgesic needs. Features such as extremes of age, dementia, neuro- trauma, neuromuscular blocking agents, and intoxicants impair a patient’s ability to express pain and limit caregiver’s clinical assessment of pain. Critical care- based studies hav e demonstrated that a high pro portion of intubated patients have recollection of discomfort and pain during the course of their illness. Furthermore, clinicians appear to attach a lower magnitude of pain to patient’s conditions than do the patients themselves. Not surprisingly then, physician prescribing behavior includes a tendency toward ineffective analgesia, oli- goanalgesia, in traumatic conditions. For the year 2004, there were almost 1.4 million hospital admissions for traumatic conditions (excluding isolated hip fractures). Of these, 176,000 involved chil- dren under the age 15. Given this magnitude and the humanitarian goals of medical practice, attention to analgesia in the multiply injur ed patient carries signifi- cant importance. The consequences of inappropriate analgesia in mul- tiply injured patients are difficult to measure. The psy- chological outcome of trauma patients hospitalized in intensive care units (ICUs) includes nightmares, pho- bias, recollection of pain and anxiety, and other ele- ments of posttraumatic stress disorder. There are few studies, however, that have demon strated that correct, over- or underutilization of analgesic or sedative agents influence these psychological outcomes. Studies that have evaluated trauma patient outcomes in relation to their physiological outcomes have not shown survival or morbidity differences. These investigations have shown differences in intermediate outcomes such as interleukin levels. It can be concluded that underutilization of analgesia to acutely injured patients is inhumane and renders patient care difficult owing to patient resistance and distress. Poorly managed analgesia and sedation may also be associated specific markers of worse patient outcomes including prolonged hospitalizations, hemo- dynamic instability, ventilator-associated pneumonia, and delirium. 79 CLINICAL ASSESSMENT OF PAIN AND MANAGEMENT OF THE MULTITRAUMA PATIENT Patient self-reporting is the most accurate means of assessing pain (Figure 12-1). There are several instru- ments that systematically define pain magnitude in the communicative patient. The visual analog scale, verbal descriptive scale, face scale, Face Legs Activity Cry Con- solability (FLACC), and modified FLACC scales have all been validated and are commonly available. Primary assessment Physical examination/imaging Treat and stabilize critical injuries Intubation: consider induction agent and sedation Bedside procedure (e.g., tube thoracostomy, major laceration) Consider regional anesthesia Consider sedation/analgesia (depending on hemodynamic status – Figure 12.2) Secondary assessment Physical examination/imaging Operative intervention (e.g., abdominal injury, head injury) Bedside procedure (e.g., laceration repair, fracture reduction) Regional and/or systemic anesthesia/sedation/analgesia Treat and stabilize critical injuries Assessment, stabilization Systemic analgesia: Figure 12.2 Figure 12-1. Trauma patient initial evaluation and sedation/analgesia algorithm. 80 Analgesia for the Emergency Patient Patients suffering multiple injuries are often incapable of focused communication. This may be from neuro- trauma, facial injuries, intoxicants, distraction, anxiety, hypoxia, therapeutically induced sedation, and paralysis. In these situations, the clinician’s appreciation of pain and its management can be easily overlooked. Alteration of vital signs is a poor indicator of pain. Compensation of hypovolemia, hyperthermia, sympa- thomimetic, or anticholinergic into xicants all may result in tachycardia or hypertension. Conversely, vagal stimu- lation, use of calcium channel, and beta receptor blocking agents, as well a s age-related cardiac conduction limita- tions, may limit the capacity for increases in heart rate and blood pressure in traumatized patients with severe pain. Patients with traumatic injuries should be considered to be in pain unless they can explicitly state otherwise. Patients with painful injuries that include alterations of their mental status or patients who are pharmacologi- cally paralyzed should receive appropriate analgesia. Likewise, anticipation of pain during procedures (e.g., wound repair, tube thoracostomy, fracture reduction, line insertion) should warrant the anticipatory admin- istration of systemic analgesia or local anesthesia despite the lack of response from the patient. In the patient with altered mental status, there may be several indicators of pain, particularly agitation. Agita- tion is a common response to pain and is in part related to increased catecholamine stimulation. Agitation also increases metabolic demands, increases the likelihood of the patient harming themselves or others, and renders the provision of care more difficult. Assessment of the bispectral index can be an adjunct to clinical examination in intubated patients under the effect of neuromuscular blocking agents or sedative procedures. This modality is a mathematic index derived from several electroencephalographic features. The bispectral index has been validated in determin- ing depth of sedation and anesth esia in both the oper- ating room and ICU. Its use has also been shown to reduce sedative agent dosing and time to waking fol- lowing general anesthesia. The range of the index spans 0–100. Zero is electroencephalographic silence and 100 is full wakefulness. Levels of 45–60 are typical of general anesthesia whereas levels of 75–80 have been associated with sedative depths appropriate for procedures and continuous sedation of injured patients. PAIN/SEDATION CONSIDERATIONS Common to many aspects of medical practice, one is more likely to reach a successful outcome, if the goals are first defined and they are realistic. Such is the case in providing analgesia in the face of complexities of the multiply injured patient. To best defin e these goals, it is useful to begin with the basic tenets of resuscitation: airway, breathing, circulation, and disability. Selection of agents and techniques to provide comfort can often be done in such a manner that physiological risk is minimized or that physiological goals can be reached as a result of analgesic intervention (Table 12-1). It is often possible to choose combinations of techniques and agents that enhance therapeutic efforts or minimize the risk of physiologic deterioration. One caveat of administration of pharmacologic agents for analgesia in patients experiencing multiple trauma is that all medications should be administered parenterally, preferably via an intravenous route. This is because GI motility and absorptive capacity as well as sphlancnic Table 12-1. Sedation and analgesia considerations for the trauma patient 1. Is the patient in pain? 2. What is/are the etiology/etiologies of the pain? 3. Is the patient hemodynamically stable? 4. What form of pain control is appropriate? (regional, systemic, both) 5. Would the patient benefit from anxiolysis or sedation? 6. What form of anxiolysis or sedation is appropriate? (benzodiazepine, neuroleptic, both) Analgesia for the Adult and Pediatric Multitrauma Patient 81 perfusion may not be predictable. This may also be true of skeletal muscle and subcutaneous perfusion. Orally administered analgesic therapy may result in erratic or delayed absorption in these patients. Additionally, the speed of onset and ability to titrate to specific analgesic endpoints are enhanced by intravenous administration. Patients with multiple injuries can have complex altera- tions in homeostatic mechanisms. Hemodynamic and respiratory consequences of their injuries are of primary importance in the emergency department setting. Once the initial resuscitation is complete, mediators of in- flammation, adrenal function, coagulation, and gastro- intestinal performance are additional considerations. Since all analgesic and sedative agents impart their own alterations in physiology, it is important to anticipate the consequences of pharmacological intervention in indi- vidual patients. All but a few pharmacological agents result in respiratory suppression and blunting of airway reflexes. Once a patient is intubated and mechanically ventilated, respiratory and airway suppression becomes less of a consideration, but the provision of ongoing ventilator sedation and analgesia begin to merge. Though intubated, the provider must always consider the ade- quacy of ventilation and the ultimate goal of extubation. PAIN AND SEDATION MANAGEMENT Nonpharmacological Approaches to Analgesia Nonpharmacological means of controlling pain should be employed whenever possible. The advantage to this approach is that the patient may feel more in con trol and there may be lesser requirements for drugs and their adverse effects. Simple measures such as ice, splinting and repositioning may have significant impact. Whenever possible, spinal clearance should take place early in the trauma patient assessment. There is evidence that spinal immobilization enhances pain. Finally, allowing family at the bedside, when feasible, and talking to the patient in a sensitive and reassuring manner may relieve anxiety and thus mitigate the pain experience. Strategies in the Provision of Analgesic and Sedative Agents Many of the agents used to provide analgesia and sedation have the effect of reducing catecholamine output and consequently vasomotor tone through reduct ion of pregang lionic a drenergic tone (Figu re 12-2 , Table 12-2 ). Thu s, if there ar e elem ents of card iac pump failure (tension pneumothorax, cardiac tamponade, congenital or acquired heart disease) or intravascular volume depletion (blood loss, transudative or exudative fluid losses), hypoperfusion may result. Propofol and the ultra–short-acting barbiturates are the agents most strongly associated with dec reases in blood pressure. Fentanyl is the opiate that is least likely to potentate hypotensio n, yet with controlled adminis- tration over 3–4 min, all opiates may be considered safe. Etomidate is the least likely of sedative agents to adversely impact hemodynamic performance. The use of ketamine increases sympathetic tone with a resulting increase in blood pressure and heart rate. This can lead to increased metabolic demands, worsening of aortic injuries and clot dislodgement from arterial injuries. Additionally, ketamine may be associated with increases of intracranial and intraocular pressures, though this effect has been contested. Nitrous oxide has been used in many facilities and prehospital agencies for control of mild to moderate pain. Nitrous oxide is commonly self-administered through a commercially available blender, which pro- vides a 50% mixture with oxygen through a demand valve (Nitronox Ò ). Its use requires an alert and coop- erative patient. One of the physical properties of nitrous oxide is that it is far more tissue soluble than nitrogen. Therefore, closed gas compartments such as pneu- mothoracies and bowel obstructions can expand as a result of nitrous oxide use. Dexmedetomidine (Precedex Ò ) is a unique agent that is classified as an a 2 adrenergic agonist. Its principal mechanism of action is to reduce CNS presynaptic norepinephrine release, thereby resulting in sedation. Hypotension and heart block have been associated with the use of dexmedetomidine. Dexmedetomidine sedation is unique in that patients experiencing sedation with this drug maintain some degree of wakefulness (along with the ability to follow commands) when stimulated. Simultaneously, respiratory depression is minimal allowing patients to sustain respiratory minute volume and ventilator tolerability. There appears to be limited impact on intracranial pressure associated with this agent. It is not approved for sedation longer than 24 hr. 82 Analgesia for the Emergency Patient The use of dexmedetomidine is reported to reduce the amount of opiates employed for analgesia and sedation in the ICU setting. Dexmedeto midine has also been demonstrated to have utility in aiding ve ntilator wean- ing. It may also be useful for endotracheal intubation when maintenance of spontaneous respirati ons is desirable. Currently there is limited experience with the use of this drug in trauma patients, but there appears to be potential benefits for selected patient populations. Patient-controlled analgesia (PCA) is a commonly employed technique for patients who are awake and can manage medication through self-administration. This strategy is based on the premise that if a patient has control over his or her own analgesia delivery, he or she No Multiply injured patient with painful injuries Mechanically ventilated Hemodynamically stable Hemodynamially unstable Hemodynamially stable Hemodynamically unstable Volume resuscitation • Non-pharmacological (positioning, reassurance) • Any opiate infusion • NSAIDs (avoid in patients at risk of renal failure or insult and gastritis) • Regional anesthesia Beware • Oligoanalgesia • Oversedation and hypoventilation • Nonpharmacological • Fentanyl infusion • Regional anesthesia Beware • Oligoanalgesia • Impaired clearance of agents with increased potential of oversedation and hypoventilation • Reduction of catecholamine output with potential of inducing hypoperfusion Age > 13 • Nonpharmacological (positioning, reassurance) • Any opiate infusion alone or in combination with Propofol or benzodiazepine infusion • Regional anesthesia Beware • Oligoanalgesia • Nonpharmacological (positioning, reassurance) • Etomidate* bolus • Fentanyl infusion alone or in combination with, benzodiazepine or ketamine* bolus if no brain injury • Regional anesthesia Beware • Oligoanalgesia • Etomidate in patients at risk of sepsis (bowel injuries, central venous access, anticipated prolonged ventilator course) Age < 13 • Nonpharmacological • Any opiate infusion alone or in combination with; • Benzodiazapine infusion • Ketamine infusion • Regional anesthesia Age < 13 • Nonpharmacological • Fentanyl infusion alone or in combination with; • Benzodiazapine • Ketamine bolus (not in the head injured) • Etomidate bolus * often used to induce sedation as part of rapid sequence intubation. Note that rapid boluses of opiates, benzodiazapines, and propofol enhance their potential to cause hypotension and respiratory suppression. • Regional anesthesia Volume resuscitation Age > 13 Yes Requires sedation and analgesia Figure 12-2. Algorithm for ongoing analgesia in multiply injured patient. Analgesia for the Adult and Pediatric Multitrauma Patient 83 Table 12-2. Sedative and analgesic agents commonly used in the multiple trauma patient Class Agent IV dose bolus a IV infusion rate b Physiologic response Unique considerations Opiates Fentanyl 2–4 mcg/kg 1–4 mcg/kg/hr BP # RR ## ICP$ Rigid chest syndrome in high doses. Least likely of commonly used opiates to result in peripheral vasodilatation Hydromorphone 0.015 mg/kg NA BP## RR# ICP$ Merperidine 0.5–1 mg/kg NA BP## RR# ICP$ Normeperidine metobolite results in potential for adrenergic crisis in patients taking MAOIs, seizure with repeated dosing Morphine 0.1–0.2 mg/kg 0.01 mg/kg/hr BP## RR# ICP$ Histamine release with urticaria near injection site and hypotension Sedative Midazolam 0.05–0.2 mg/kg 0.02–0.1mg/kg/hr BP# RR## ICP# Considerable variation in therapeutic window. Start with lower doses in the young and elderly Lorazapam 0.05–0.1 mg/kg 0.02–0.03mg/kg/hr BP# RR## ICP# Propofol 1–2 mg/kg over 1 min 25–125 mcg/kg/hr BP### RR### ICP## Avoid propofol infusions in children less than 13 years of age owing to rare but fatal occurrence of cardiac failure. Venous irritation Etomidate 0.1–0.2 mg/kg over 1 min BP$ RR# ICP# Least destabilizing of sedative agents. Myoclonus. Adrenal suppression following single dose as well as continuous infusions. Shown to have outcome impact in sepsis with no trauma studies to date affecting outcome Dissociative Ketamine 0.5–4 mg/kg 0.3 mg/kg/hr BP" HR"" RR$ ICP" Sympathomimetic. Hypersalivation and emergence reactions. Sedation is marked by dissociation. There is often wakefulness during this period. Highly analgesic beyond duration of sedation. Very wide therapeutic window Notes: a All dosing are based on ideal body weight. b Unless otherwise specified, all of these agents should be administered over 2–4 min. 84 will experience less breakthrough pain and anxiety. Generally, a provider obtains an adequate level of an- algesia through carefully titrated opioid administration. Thereafter, a continuous basal infusion of an opioid is established and the patient can deliver supplemental boluses of the same opioid with the push of a button attached to a delivery pump. The basal infusion rate, doses of patient administered boluses, and hourly limits on boluses are programmed into the delivery pump, which ensures these parameters. It is typical that a PCA be initiated following the initial evaluation and management of most injuries. PCA management of pain has not been shown to be suitable as a means of procedural analgesia or sedation. In the setting of multiple traumatic injuries, particu- larly if the patient is being mechanically ventilated, the provision of analgesia mingles with sedation. There are several agents, which serve to meet both of these needs. It is often desirable to titrate more than one agent to minimize the deleterious effects of either drug alone. Since the experience of pain includes components of anxiety, there is often a role for pure sedative agents in enhancing pati ent comfort. Therefore, the decision to use both a benzodiazepine and an opiate continuous infusion may reduce the potential for hypotension. Likewise, addition of an opiate infusion to a propofol infusion to a patient with painful injuries would be expected to reduce the dosage requirement for both, thus reducing the occurrence of hypotension. Traumatic brain injury (TBI) is a common component of multiple trauma. Improving the outcome of TBI patients relies principally upon avoidance or reduction o f secondary brain in jury. T he overriding consideration i n the acute management of TBI is maintenance of ventila- tion and cerebral perfusion pressure (CPP). Therefore, hypotension and hypoventilation, based u pon the dele te- rious effect on CPP, have been repe atedly associated with adverse outcomes in patients with severe brain injury. Several of the agents used to provide analgesia or sedation can have either positive or negative impact on CPP depending upon how they ar e used. Thus, carefu l attention to maintenance of blood pressure is a key element in providing sedation and analgesia to patients with severe head injury. Propofol is the prototypical agent shown to maintain cerebral blood flow and reduce ICP in the presence of adequate intravascular volume. Additional ly, propofol is an effective anticonvulsant and the least likely to result in vomiting. However, propofol in the hypovolemic patient or the patient with limitations of cardiac output will potentate hypotension. The reduction of CPP however, in the face of propofol-induced hypotension is not proportional to the reduction of blood pressure due to the reduction of systemic vascular resistance. Regional and Local Anesthesia The use of regional anesthesia is often overlooked in the initial management of the multiple trauma patient. There are several techniques that are well within the technical reach of emergency physicians, trauma sur- geons, and orthopedists. These can greatly enhance the comfort of patients and avoid or reduce the adverse effects of systemic analgesia. Intercostal and femoral nerve blocks are examples of regional anesthesia that can reduce pain and opiate requirements in selected patients. Epidural blocks in the setting of chest trauma have been shown to reduce mortality, pneumonia, ventilator initiation, and days on a ventilator. Epidural blocks are contraindicated in cases where clinical examination of the abdomen is required due to anesthesia below the level of the block. Generally, an epidural block is initi- ated and maintained by an anesthetist or anesthesiolo- gist. Epidural catheters may be placed and left in position for as long as several days. When using regional or local anesthesia for control of pain, long-acting agents (bupivucaine) are preferred. SUMMARY The provision of analgesia and sedation are fundamental skills in managing the multiply injured patient. These patients are complex from many standpoints and the administration of pharmacological agents to manage pain and affect sedation serve to increase their com- plexity. To safely and effectively provide sedation and anal- gesia to the trauma patient, the provider must be able to identify specific goals, anticipate the combined physio- logical effects of the injuries and analgesic modalities employed. There is no single practice or technique that Analgesia for the Adult and Pediatric Multitrauma Patient 85 has proven safe or effective in all patients. For any in- dividual, several techniques for providing analgesia and sedation will be equally safe and effective. BIBLIOGRAPHY 1. van de Leur JP, van der Schans CP, Loef BG, Deelman BG, Geertzen JH, Zwaveling JH. Discomfort and factual recollection in intensive care unit patients. Crit Care 2004;8:R467–R473. 2. Guru V, Dubinsky I. The patient vs. caregiver perception of acute pain in the emergency department. J Emerg Med 2000;18:7–12. 3. Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P. Emergency department analgesia for fracture pain. Ann Emerg Med 2003;42:197–205. 4. Moon MR, Luchette FA, Gibson SW, et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg 1999;229:684–691. 5. Petrack EM, Christopher NC, Kriwinsky J. Pain manage- ment in the emergency department: Patterns of analgesic utilization. Pediatrics 1997;99:711–714. 6. Young J, Siffleet J, Nikoletti S, Shaw T. Use of a Behavioural Pain Scale to assess pain in ventilated, unconscious and/or sedated patients. Intensive Crit Care Nurs 2006;22:32–9. 7. Trope RM, Silver PC, Sagy M. Concomitant assessment of depth of sedation by changes in bispectral index and changes in autonomic variables (heart rate and/or BP) in pediatric critically ill patients receiving neuromuscular blockade. Chest 2005;128:303–307. 8. Miner JR, Biros MH, Seigel T, Ross K. The utility of the bispectral index in procedural sedation with propofol in the emergency department. Acad Emerg Med 2005;12:190– 196. 9. Miner JR, Biros MH, Heegaard W, Plummer D. Bispectral electroencephalographic analysis of patients undergoing procedural sedation in the emergency department. Acad Emerg Med 2003;10:638–643. 10. Kwan I, Bunn F. Effects of prehospital spinal immobiliza- tion: A systematic review of randomized trials on healthy subjects. Prehosp Disaster Med 2005;20:47–53. 11. Bourgoin A, Albanese J, Wereszczynski N, et al. Safety of sedation with ketamine in severe head injury patients: Comparison with sufentanil. Crit Care Med 2003;31: 711–717. 12. Avitsian R, Lin J, Lotto M, Ebrahim Z. Dexmedetomidine and awake fiberoptic intubation for possible cervical spine myelopathy: A clinical series. J Neurosurg Anesthesiol 2005;17:97–99. 13. Triner W,Levine J, Lai SY, McErlean M. Femoral nerve block for femur fractures. Ann Emerg Med 2005;45:679. 14. Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: The breakpoint for mortality. Surgery 2005;138:717–723. 15. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery 2004;136:426–430. 16. Green SM, Clark R, Hostetler MA, Cohen M, Carlson D, Rothrock SG. Inadvertent ketamine overdose in children: Clinical manifestations and outcome. Ann Emerg Med 1999;34:492–497. 86 Analgesia for the Emergency Patient 13 Analgesia for the Emergency Department Isolated Orthopedic Extremity Trauma Patient Michael A. Turturro SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN CONSIDERATIONS PAIN MANAGEMENT FOLLOW-UP/CONSULTATION CONSIDERATIONS SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM Acute orthopedic injuries are among the most common conditions seen in the emergency department (ED). In 2004, fractures, sprains, strains, and contusions accounted for 14.3 million of the total 110.2 million ED visits in the United States. Acute orthopedic injuries typically cause acute pain and consequent guarding of the injured part by the patient in an effort to reduce the pain. Although thi s innate response prevents further injury, appropriate initial management of pain will allow more rapid mobilization and return to normal function. Conversely, uncontrolled pain may lead to adverse physiologic consequences such as prolonged immobili- zation increasing the risk of thromboembolic comp li- cations, limitatio n of range of motion, and muscular atrophy. CLINICAL ASSESSMENT The extent of acute orthopedic injury can often be predicted by the mechanism of injury. For example, a fall on an outstretched hand may indicate a Colle’s, scaphoid, or radial head fracture; a twisting injury to the knee with an audible pop may indicate a rupture of the anterior cruciate ligament. First and foremost in the examination of acute orthopedic injuries is a primary survey to detect potential life-threatening injuries. Then, a general assessment of the injured part by inspection, palpation, and range of motion should be performed to exclude immediate limb threats (e.g., a fracture dislocation of the ankle with vascular compromise) and to assess for deformity, limi- tation of range of motion, and overlying soft tissue injuries. The skin examination should focus on the detection of abrasions, puncture wounds, and lacerations that could require repair. A more thorough examination should be undertaken to assess for additional injuries, regardless of severity. Though it is important to thoroughly evaluate areas obviously injured and areas in which the patient com- plains of discomfort, additional injuries could poten- tially be overlooked unless a more thorough examination is performed. Finally, neurovascular assessment should be under- taken to evaluate for associated nerve or limb-threatening vascular injuries and to recognize signs associated with a potential compartment syndrom e, in which the most common and earliest sign is pain (Table 13-1). Plain film radiographs should be ordered if on history an examination there is concern for either a fracture or a dislocation. Well-validated clinical decision rules have been developed and implemented for the appropriate use of plain film radiography in acute ankle and knee injuries. Since not all fractures are immediately radiographically apparent, if there is a strong clinical suspicion for a 87 [...]... high-speed grinding In this case Seidel’s test can be used to aid in the diagnosis PAIN CONSIDERATIONS Both eye and ear complaints are common in the ED and can elicit significant pain It is important to recognize pain early and treat effectively, particularly as examinations of the eye and ear can worsen a patient’s pain and anxiety Children presenting with AOM often have significant pain, anxiety, and. .. depression is part of the etiology, there are genetic predispositions, and abnormal thalamic pain modulation plays a role Figures 1 5-1 –1 5 -4 display a theory for primary headache etiology In this model, the pain expression system (that which makes things hurt) is activated by Pain expression system Pain transmission system Trigeminovascular system Migraine syndrome Second- and third-order neurons Sensory and. .. morphine in the treatment of chest pain in patients with suspected acute myocardial infarction - the MEMO study J Intern Med 1999; 245 :133– 141 3 Everts B, Karlson B W, Wahrborg P, Hedner T, Herlitz J Localization of pain in suspected acute myocardial infarction in relation to final diagnosis, age and sex, and site and type of infarction Heart Lung 1996;25: 43 0 43 7 4 Exhauser A, Andrews RM, Fox SF Clinical classifications... improvement study J Pain 1995;6:639– 643 8 Center for Disease Control and Prevention, National Center for Health Statistics, Adv Data 2006;372:1–29  14 Analgesia for Selected Emergency Eye and Ear Patients Matthew G Dunn SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN CONSIDERATIONS PAIN MANAGEMENT Otologic Ophthalmic FOLLOW-UP/CONSULTATION CONSIDERATIONS SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM Eye and ear problems... 2002;18(7) :41 4 43 9 5 Morgenstern LB, Huber JC, Luna-Gonzales H, et al Headache in the emergency department Headache 2001 ;41 (6):537– 541 6 Maizels M, Health resource utilization of the emergency department headache ‘‘repeater.’’ Headache 2002 ;42 (8): 747 –753 7 Jakubowski M LD, Goor-Aryeh I, Collins B, Bajwa Z, Burstein R Terminating migraine with allodynia and ongoing central sensitization using parenteral... Dougherty J, White W Randomized double-blind trial of intravenous prochlorperazine for the treatment of acute headache JAMA 1989;261(8):11 74 1176 14 Jones EB, et al Safety and efficacy of rectal prochlorperazine for the treatment of migraine in the emergency department Ann Emerg Med 19 94; 24( 2):237– 241 15 Jones J, Pack S, Chun E Intramuscular prochlorperazine versus metoclopramide as single-agent therapy for... with chest pain, important characteristics of the pain should be elicited These details would include the speed of onset, site, radiation, quality, and intensity Further characterization of the pain should include duration and 103 1 04 Analgesia for the Emergency Patient Table 1 6-1 Common causes of acute chest pain Visceral pain Chest wall pain Pleuritic pain Aortic dissection Mitral valve prolapse Esophageal... excellent choices for intravenous management For outpatient management, oxycodone or hydrocodone preparations will be effective for pain in excess of that controlled by NSAID therapy alone FOLLOW-UP/CONSULTATION CONSIDERATIONS Follow-up and consultation chest pain patients will be driven by the etiology of the pain syndrome Inflammatory and musculoskeletal-based chest pain will often last for a period... 2001;38:129–1 34 9 Michael JG, Hug D, Dowd MD Management of corneal abrasion in children: A randomized clinical trial Ann Emerg Med 2002 ;40 :67–72 10 Weaver CS, Terrell KM Evidence-based emergency medicine Update: Do ophthalmic nonsteroidal antiinflammatory drugs reduce the pain associated with simple corneal abrasion without delaying healing? Ann Emerg Med 2003 ;41 :1 34 140 15 Analgesia for the Emergency. .. anti-inflammatory drugs (NSAIDs), narcotics, and acetaminophen PAIN MANAGEMENT Approaches to the treatment of primary headache pain in the ED are outlined in Table 1 5 -4 Once a secondary 100 6 mg sub cu 20 40 mg PO 2.5 mg PO 10 mg PO 5 mg PO 2.5 mg IV, 5 mg IM 5 mg IV, 10 mg IM 500–1,000 mg/day 10 mg IM/IV 10–20 mg IV 1 mg IV, 4 mg IN 900 mg/day start 500 mg 50 mg PO 1 g IV 100 mg TID Topically applied 4% . departments. J Behav Med 1998;21 (6): 545 –563. 14. Larsen MJ, Fosnocht DE, Swanson ER. Pain management after discharge from the emergency department. Ann Emerg Med 20 04; 44( 4):S88. 15. Todd KH. Pain. Pain and pain- related functional interference among discharged emergency department patients. Ann Emerg Med 20 04; 44( 4):s86. 78 Analgesia for the Emergency Patient 12 Analgesia for the Adult and. OF PAIN AND MANAGEMENT OF THE MULTITRAUMA PATIENT PAIN /SEDATION CONSIDERATIONS PAIN AND SEDATION MANAGEMENT Nonpharmacological Approaches to Analgesia Strategies in the Provision of Analgesic and