Download JAGODA_Pain_Management - well

Clinical Decision Making in
Pain Management:
The Panel
Andy Jagoda, MD, FACEP, Professor of Emergency
Medicine
Mount Sinai School of Medicine, New York, New York
Robert Asselta, RN, BSN, CEN, Paramedic, Education
Specialist Mount Sinai Emergency Department
Alex Manini, MD, MS, Toxicologist and Research Director,
Elmhurst Medical Center
Ron Walls, MD, Professor and Chair, Brigham and Women’s,
Harvard School of Medical Student
Overview
•
•
•
•
Scope of the problem
Mechanisms of pain
Case studies Management options
Future directions: Is there a need to
change practice
Key Points
• Management of pain must be placed in the context of the
clinical presentation
 Underlying mechanism of pain impacts approach to
managing the pain
• Treatment should not be delayed pending a diagnosis
• IV titration is generally the preferred approach for severe acute
pain
 Treat early, front-load, around the clock
 Acute management must be linked to the continuum of care
• Opioids are not always best and NSAIDs are not benign
• Non-pharmacologic management and anxiolysis play an
important role in the pain response
ACEP Pain Policy Statement March 2004
•ED patients should receive expeditious pain management,
avoiding delays such as those related to diagnostic testing or
consultation.
•Hospitals should develop unique strategies that will optimize ED
pain management using both narcotic and non-narcotic
medications.
•ED policies and procedures should support the safe utilization
and prescription writing of pain medications in the ED.
•Effective physician and patient educational strategies should be
developed regarding pain management, including the use of pain
therapy adjuncts and how to minimize pain after disposition from
the ED.
•Ongoing research in the area of ED patient pain management
should be conducted.
Background
• Pain is the most common reason people come to the ED
 Accounts for 70% of ED visits
 Children and the elderly are commonly undermedicated
• Varying levels of understanding of pain and its treatment
exist
 Many patients come to the ED out of desperation
• Pathways
 Nociceptive: activation of primary peripheral pain
receptors (A-delta and C fibers)
 Neuropathic: aberrant signal processing in the
peripheral or central nervous system
Pain treatment options
•
•
•
•
•
•
Eliminate mechanical and environmental factors
Block opiate receptors
Block inflammatory mediators
Block transmission to the CNS: local anesthetics
Modulate central 5-HT pathways
Modulate the “close gates” at dorsal horn: TENS,
acupuncture
• Decrease anxiety
• Maximize placebo effect
The Cases
• Severe dirty “road rash” traumatic injuries in
16 year old boy skateboarder who did one too
many flips
• Progressive, diffuse severe abdominal pain in
a 72 year old man
• Severe sudden onset headache associated
with vomiting in a 28 year old woman
• Acute pain crisis in a 34 year old patient with
sickle cell disease
Myths
• You can assess severity of pain by looking at the
patient and the vital signs
• Fear of adverse reactions
 Rare and generally preventable
• Fear of masking critical clinical findings
 Questionable and unlikely if judgement used
• Fear of inducing addiction
 Rate of 1/3,000 pts in Boston study
• Patients will request pain medication if they need it
 70% of pts will not request Tx despite pain
• IM treatment saves time and money
Who are you?
a)
b)
c)
d)
e)
f)
g)
Emergency nurse
Other nurse
Physician
Resident
EMT
Medical student
Other
Do you think EDs do a good job treating pain?
a) Yes
b) No
If you present to the ED, how long is reasonable
before you receive your first dose of analgesic?
a)
b)
c)
d)
10 minutes
30 minutes
60 minutes
120 minutes
Do you think there is a role for complimentary
medicine in ED practice?
a) Yes
b) No
16 yo skate boarder; flipped going down hill and skidded 30
feet. Severe pain in face and arm with deformity of arm.
Denies LOC, amnesia, headache, neck pain
EMS
• The patient is in severe pain with transport time of
35 minutes
 What are the primary prehospital concerns?
 Should this patient be given analgesia during
transport?
ED Triage
• When the patient arrives in the ED, how is his pain
assessed?
• How often should his pain be reassessed?
• What are the initial nursing concerns in managing
this patient?
What would be your first line treatment for this
patient’s pain?
a)
b)
c)
d)
e)
f)
Tylenol po
Motrin po
Torodol IM
Percocet po
Morphine IV
Fentanyl IV
Do you agree with nurse initiated
administration of narcotics for acute pain?
a) Yes
b) No
Management
• How would you recommend pain control for
debriding / cleaning this patient’s wounds?
• Is there a role for comlimentary medicine adjuncts
or other nonpharmacologic approaches?
Analgesics
• Acetaminophen: no antiplatelet effect, no anti-inflammatory
effect; acts in CNS
• NSAIDS
 Inhibit prostaglandin synthesis by interfering with
cyclooxygenase (COX) enzymes
 Cause platelet dysfunctions
 Can impact renal function
 Increase risk of GI bleeding
 COX-2 agents preferentially inhibit the COX-2 enzyme
that is induced by inflammatory stimuli and is
responsible for the activation and sensitization of
nociceptors
Nonsteroidals
• Are NSAIDS contraindicated in trauma / perioperative
patients
• Do NSAIDs interfere with bone healing
• Is IM or IV ketoralac better than po NSAISS
 Toradol is contraindicated as prophylactic analgesic
before any major surgery, and intraoperatively
whenever hemostasis is critical1
 Does have significant antiplatelet effects in clinical
trials2
• Large case-control study did not show increased bleeding
when given peri-op to surgical patients3
NSAIDs in Perspective
• No NSAID has been proven significantly more
efficacious than another, when given in equivalent
doses
 Select agents based on toxicity profiles?
 Side-effect rates generally parallel half-life
profiles
• Patient response can vary between agents
 Multiple categories of agents
• No difference in efficacy by mode of administration
Progressive, diffuse severe abdominal pain in
a 62 year old man
• History of hypertension,
hyperlipidemia, smoking,
diabetes
• Pain began 2 days prior
and has been progressive
with some localization in
the right lower quadrant
• VS at triage: 140/90, 80,
16, pulse ox 98%
• Overall looks well
How would this patient be triaged and where would
he be placed in the ED?
On exam the patient has significant diffuse
tenderness with rebound; stool is guaiac neg
•
•
What is the differential diagnosis
Surgery is called; a CT is ordered
•
Should this patient receive pain medication while
waiting for the evaluation to be completed
a) Yes
b) No
Opioids
• Agonists:
 Rule of ten
 0.1mg
fentanyl
(Duragesic)
 1 mg
hydromorphone
(Dilaudid)
 10 mg
morphine
 100 mg meperidine
(Demoral)
 Codeine (metabolized to
morphine / high nausea)
 Methadone
 Oxycodone (Oxycontin)
 Oxymorphone (Numorphan)
• Agonists – Antagonists
 High dysphoria rates)
 Ceiling analgesia and
respiratory depression
 Buprenorphine (Buprenex)
 Butorphanol (Stadol)
 Nalbuphine (Nubain)
 Pentzocine (Talwin)
• Other
 Tramadol (Ultram)
 Weak binding to the
opiate receptor
 Inhibits reuptake of both
NE and 5-HT
Opioids: Meperidine (Demerol)
• Many EDs no longer stock it
 Metabolism prolonged in renal or
hepatic disease
 Metabolite (normeperidine) is a CNS
toxin
 Can induce the Serotonin Syndrome
• Highest rate of associated euphoria
 Problematic patients often request it
Opioids: New strategies
• Less meperidine and morphine
• Early, rapid control with fentanyl
 Titrate IV
 Limit total dose
• Maintenance with hydromorphone
 Start 5 -30 minutes later
 Well tolerated
 No maximum dose
Severe sudden onset headache associated
with vomiting in a 28 year old woman
• History of migraines
• No new medications
• Vital signs: 110/70, 60,
14
• How would this patient
be triaged?
Which of the following is first line treatment for
treating acute severe migraine?
a)
b)
c)
d)
e)
Prochlorperazine (compazine)
Ketorolac (torodol)
Morphine
Fentanyl
Tramadol (ultram)
Centrally acting agents
• 5HT receptor modulators
 Phenothiazine
 Triptans
• Tricyclics
• Carbamazepine
• Gabapentin
• Valproic acid
Pain Therapy: Point Injections
• “Trigger” or other point injections may represent an
attractive and viable option in selected patients

Lower cervical injections for headache relief.
Mellick GA, Mellick LB. Headache 2001.41(10): 992

Pericranial injection of local anesthetics in the
ED management of resistant headaches
Brofeldt, Panacek. Acad Emer Med. 1998.
Acute pain crisis in a 34 year old patient with
sickle cell disease
• Acute pain crisis in a
34 year old patient
with sickle cell disease
• Pain in all joints similar
to past crises
• No preceeding illness
• Requests IV Dilaudid 4
mg
Acute on Chronic Pain
• What is the current best practice strategy in
managing sickle cell pain
• Is there a role for continuous infusion pumps in
the ED
• Is there a role for alternative medicine
approaches to modulating chronic pain
syndromes
Future directions
• Improve nurse and physician understanding of
mechanisms of pain
 Improve clinician / patient communication
• Improve strategies for choosing the right
intervention for the right patient
• Well designed comparative clinical trials
• Improve analgesic delivery systems
• Improve strategies for providing a continuum of
pain management after discharge from the ED
Key Learning Points
• Management of pain must be placed in the context of the
clinical presentation
 Acute vs chronic; nociceptive vs neuropathic
 Underlying mechanism of pain impacts approach to
managing the pain
• Treatment should not be delayed pending a diagnosis
• IV titration is generally the preferred approach for severe acute
pain
 Treat early, front-load, around the clock
 Acute management must be linked to the continuum of care
• Opioids are not always best and NSAIDs are not benign
• Non-pharmacologic mangementment and anxiolysis play an
important role in the pain response