PAIN MANAGEMENT

1. In adult
2. In paeds
PAIN MANAGEMENT IN
ADULT
PAIN MANAGEMENT IN ADULT
More than 60% of patients registering in EDs
have pain as their primary symptom

40% of patients may have chronic pain

underlying their complaint

45% of all emergency patients are suffering from

acute pain
PATHOPHYSIOLOGY
response to a noxious stimulus
expression of pain is modified by the complex
interaction of cognitive, behavioral, and
sociocultural dimensions
involves the release of potent mediators of
inflammation and is modulated by neurocognitive
factors resulting in an unpleasant sensory and
emotional experience
 PNS generates the sensation of somatic pain by
registering the original noxious stimulus and
conducts it to the CNS

releases excitatory neurotransmitters in the

dorsal root ganglion and the dorsal horn of the
spinal cord

Supraspinal center integrate and process pain

information, allowing detection and perception of
pain.

visceral pain pathways are more complex and

differ in structure from somatic pain pathways
(poor localization of visceral pain)
KEY PRINCIPLES
Assess severity
Use appropriate doses of analgesics

Titrate doses to control pain

Monitor for adverse effects

PAIN SCALES

quantitate pain severity

use the quantitative measures to select and
administer the appropriate type of analgesic
agent
reassess the pain response to determine the need
for repeated doses or more effective analgesics
value assigned by a patient is not an absolute
value but rather a reference point based on past
personal experience
PAIN SCALES
Adjective
Visual
Numeric
5-Point
Verbal analog
quantitative
global
rating
rating
scale
scale
scale
scale
ADJECTIVE RATING SCALE

Patient rates pain by choosing from an ordered

list of pain descriptors
Easy to administer
VISUAL ANALOG SCALE

Patient places a mark that best describes pain intensity

along a 10-cm linear scale marked at one end with a
term such as no pain and at the other end with worst
imaginable pain
measured in millimeters from one end
NUMERIC RATING SCALE

The patient is asked to self-report pain on a scale

of 0 to 10 with descriptors
Can be used in patients with visual, speech, or
manual dexterity difficulties
5-POINT GLOBAL SCALE
Patient rates pain as:
0 = none
1 = a little
2 = some
3 = a lot
4 = worst possible

A decrease of one point is a large change

Allow monitoring of small changes in pain and
may be more sensitive
VERBAL QUANTITATIVE SCALE
The patient is asked to self-report pain on a scale
of 0 to 10 without descriptors.

Most commonly used scale, easy to administer.

 The end point for pain management is the
patient's judgment about pain relief

The interpretation of pain is variable, and the

only relevant goal should be that which satisfies
the needs of the patient
PAIN TREATMENT
selection of an agent appropriate for the intensity of pain, prompt
onset of analgesic activity, ease of administration, safety, and efficacy

tiered approach - starting with an agent of low potency and adding or

changing to agents of higher potency if pain persists

NSAIDs - mild to moderate pain

systemic opioids - moderate to severe pain.

In specific instances (renal/biliary colic) a parenteral NSAID may

control severe pain, although combination therapy with an opioid is
usually superior.

When indicated or possible, local or regional neural blockade is a

useful adjunct
 COMPARISON OF PHARMACOLOGIC
CLASSES
Class Route Advantages Disadvantages
NSAIDs PO Mild/moderate somatic Use caution in the elderly and
pain plus severe colicky in those with renal, GI, and
pain hematologic disorders
Parenteral Does not require GI No more effective than
absorption more costly
Opioids PO Can be effective if Variable absorption,
adequately dosed somewhat slower onset
IM No IV access required Painful injections; unreliable
absorption
IV Ideal for titrated dosing Need for IV access
Local anesthetics Infiltration Technical ease Limited duration of action
Peripheral nerve block Opioid sparing Technical difficulty, may be
facilitated with use of
guidance
Regional anesthesia Opioid and general Risk of autonomic instability,
anesthetic sparing hemodynamic collapse
OPIODS
OPIOID ANALGESICS
Opioid use in the ED is often affected by concern for the
precipitation of adverse events, such as respiratory
depression or hypotension, or for facilitating drug-
seeking behavior
Our greatest concerns, however, should be the underuse

of opioids and inadequate dosing when used

Route of administration and desired time of onset of action
Initial dose
frequency of administration titrated against analgesic
response
Concurrent use of nonopioid analgesics and adjunctive agents
Incidence and severity of side effects
Whether the analgesic will be continued in an inpatient or
ambulatory setting
 DOSING OF COMMON OPIOID
ANALGESICS FOR ACUTE, SEVERE
PAIN
Drug Typical Adult Dose Pharmacokinetics Comments
Morphine 0.1 mg/kg IV Onset: 12 min (IV) and 10 Histamine release may
15 min (IM/SC) produce transient
10 mg IM hypotension or nausea
0.3 mg/kg PO Peak effect: 35 min (IV) and and emesis, neither
1530 min (IM) require routine
adjunctive treatment
Duration: 12 h (IV) and 34 nausea and emesis
h (IM/SC)

Hydromorphone 0.015 mg/kg IV Onset: 35 min (IV) -

12 mg IM Peak effect: 710 min (IV)
Duration: 24 h (IV)

Fentanyl 1.0 mcgm/kg IV Peak effect: 25 min (IV) High doses can cause
chest wall rigidity (>5
Duration: 3060 minutes (IV) mcgm/kg IV)
Meperidine 1.01.5 mg/kg Onset: 5 min (IV) CI when patient taking a
(pethidine) IV/IM monoamine oxidase inhibitor;
Peak effect: 510 min (IV) neurotoxicity may occur when
multiple doses given in the
Duration: 23 h (IV) presence of renal failure

Oxycodone 510 mg PO Onset: 1015 min (PO) -Lower incidence of nausea

-Possible inadvertent
30 mg PR Duration: 36 h (PO) acetaminophen overdose with
combination agents

Hydrocodone 510 mg PO Onset: 3060 min (PO) - Lower incidence of nausea

- Possible inadvertent
Duration: 46 h (PO) acetaminophen overdose with
combination agents

Codeine 3060 mg PO Onset: 3060 min (PO) - High incidence of GI side

effects
30100 mg IM Duration: 46 h (PO) - Possible inadvertent
acetaminophen overdose with
combination agents

Tramadol 50100 mg PO Onset: 1015 min (PO) CNS side effects common
Duration: 46 h (PO)
 The use of meperidine has been discouraged for several reasons
itis often underdosed
meperidine can interact with many drugs to precipitate a serotonin
syndrome
metabolism of the parent drug to normeperidine, which has
neuroexcitatory properties and a long elimination half-life (24 to 48 hours)
The potential for normeperidine accumulation and toxicity is greater in
the elderly and those with renal failure

Codeine use has also decreased, mainly because codeine produces

more nausea, vomiting, and dysphoria than other opioids.
The analgesic effect of codeine is highly dependent on the metabolic

conversion to the active metabolites codeine-6-glucuronide and

morphine.
Up to 10% of the U.S. population is deficient in the relevant

enzymes for this conversion and therefore have an inadequate

analgesic response to codeine
ADVERSE EFFECTS
Nausea
Vomiting

Constipation

Pruritus

urinary retention

Confusion

respiratory depression

Adjuncts (such as promethazine, hydroxyzine,

midazolam, ketamine, and NSAIDs) have sometimes
been used to enhance the analgesic effect, reduce the
amount of opioid required, and prevent side effects
ADJUNCTS
enhance the analgesic effect
reduce the amount of opioid required

prevent side effects

Depending on the agent, amount, route, and

setting, a beneficial effect can be seen

Pretreatment with antiemetics is not necessary
given the low risk of emesis, but symptom-
targeted therapy with anxiolytics and antiemetics
is sometimes necessary
 ADJUNTS
Drug Initial Dosing Pharmacokinetics Comments

Prochlorperazine 510 mg IV/IM Duration: 46 h Can cause

extrapyramidal
reactions
Promethazine 2550 mg IV/IM Duration: 46 h Can cause
extrapyramidal
reactions
Metoclopramide 510 mg IV/IM Duration: 46 h Primary action is
gastric emptying
OPIOD AGONIST-
ANTAGONIST
 minimize some of the adverse effects of pure
opioid agonists
The major benefit has been a ceiling on
respiratory depression: no further reduction in
respiration with increasing doses past a set
amount
It is not clear if there is a ceiling effect for

analgesia
should be used with extreme caution in patients
with opioid addiction because they may
precipitate withdrawal symptoms
Drug Initial Dosing Pharmacokinetics Comments
Buprenorphine 0.3 mg IV/IM every 6 Onset: rapid Sedation, dizziness,
h nausea
1216 mg SL once a Duration: 410 h
day
Butorphanol 0.52.0 mg IV every Onset: <1 min Sedation, dizziness,
34 h nausea
14 mg IM every 34 Duration: 24 h
h
Dezocine 2.510.0 mg IV Onset: 15 min (IV)
every 4 h and 30 min (IM)
520 mg IM every 6 Duration: 46 h
h
Nalbuphine 1020 mg IV/IM/SC Onset: 23 min (IV) Sedation, headache,
every 36 h and 30 min (IM) dizziness
Duration: 36 h
Pentazocine 30 mg IV/IM/SC Onset: 23 min (IV) Central nervous
every 36 h and 1520 min (IM) system side effects
NON OPIOD
 NSAIDs, including aspirin, naproxen, indomethacin,
ibuprofen, and ketorolac, are excellent analgesics and anti-
inflammatory agents

As analgesics, bind to induced COX 2 receptors in the

dorsal horn of the spinal cord

As anti-inflammatory agents, decrease the release of

prostanoids and arachidonic

do not cause sedation or respiratory depression or interfere

with bowel or bladder function.

significant opioid dose-sparing effects.

ADVERSE EFFECTS
platelet dysfunction
Nephropathy

Headaches

Dizziness

GI irritation

Bleeding

All NSAIDs increase the risk of cardiac death in

patients at risk for ischemic heart disease, although the

COX 2 specific agents appear to carry the highest risk
for this complication
induced ARF and is more common in elderly patients
and in those who are volume depleted, have preexisting
renal or cardiac disease, or are taking loop diuretics
Drug Adult Dosage Toxicity
Acetaminophen 6501000 mg PO every 4 h Liver dysfunction and necrosis

12 g PR every 4 h
Aspirin 6501000 mg PO 4 h Reye syndrome in children, tinnitus,
central nervous system toxicity,
metabolic acidosis
Ibuprofen 400800 mg PO every 46 h GI upset, platelet dysfunction, renal
dysfunction, bronchospasm
Naproxen 250 mg PO every 68 h GI upset, platelet dysfunction, renal
dysfunction, bronchospasm plus interacts
5001000 mg PR every 68 h with protein-bound drugs
Indomethacin 2550 mg PO every 12 h GI upset, platelet dysfunction, renal
dysfunction, bronchospasm
100 mg PR every 24 h
Ketorolac 1530 mg IV every 6 h GI upset, platelet dysfunction, renal
dysfunction, bronchospasm; much
3060 mg IM greater risk of GI bleeding than
ibuprofen; use limited to 3 d IV and 5 d
OTHER AGENT
KETAMINE
produces analgesia and dissociative anesthesia with
the advantage of causing minimal respiratory
depression.
ability to produce amnesia makes it a good agent for

brief, minor procedures, such as wound repair

Low-dose infusions of ketamine are effective in

combination with opioids for patients in severe pain. 21

It is commonly stated that ketamine increases ICP,

which limits its use in many emergency situations.

Adverse effects include hypersalivation and
reemergence phenomena (disagreeable dreams or
hallucinations upon awakening), especially when
induction dosing is used (1.5 milligrams/kg).
NITROUS OXIDE
fast-onset, short-acting analgesic and sedative
inhalational agent useful for wound dressing and
brief, minor procedures
primary adverse effects are nausea and vomiting.

Nitrous oxide is usually supplied as a preblended

50% mixture with O2 and administered to the
patient by face mask.
cannot be used in patients with altered mental
status, head injury, suspected pneumothorax, or
perforated abdominal viscus alter the
respiratory elimination of nitrous oxide.
CYCLIC ANTIDEPRESSANTS AND
ANTICONVULSANTS
Patients with neuropathic pain are difficult to treat
with standard analgesics and may be resistant to
short-acting opioids.
Long-acting opioids, cyclic antidepressants, and

anticonvulsants have all been found to be effective

for neuropathic pain
When initiating such agents for selected patients,

ensure follow-up with the primary care physician so

that titration to effect may continue
Patients already taking one of these agents may

require either titration upward of their medication

or addition of a second agent; this should usually be
discussed with each patient's regular physician.
PAIN MANAGEMENT IN
PAEDS GROUP
AGE GROUP
AGE GROUP
Newborn & infant (0-9 months)
Can be examined independent of his parents
Toddler (10-30 months)
"stranger anxiety
Separation from a caregiver causing great distress.
parental presence and even participation in the preparation for painful
procedures is important.
should be examined, in their parents' laps or arms
Parents may lie on the stretcher with the patient to provide comfort
School aged (4-10 years)
begun to individuate from parents
can be engaged in conversation
They can conceptualize time (abstraction), so pain that lasts "only for a count
of 10" can be mitigated by such a counting activity
Physical restraint may be challenging and even dangerous for the patient and
provider given the larger size and increased strength of school-aged children
Preadolescences & adolescences (11-18 years)
Physical modesty is extreme in preadolescence and adolescence
Anxiety can be intense, and behaviors can regress
Cognitive developmental delay
PAIN MANAGEMENT
analgesic
ANXIOLYSIS
NONPHARMACOLOGIC ANXIOLYSIS
Parental presence is a fundamental technique to
reduce anxiety that is both cost-free and
technically easy to apply
parental presence used may vary by age, but
generally, for painful procedures, a well-prepared
parent can "coach" the child and reduce anxiety
At older ages, although there are certainly parts

of the teen history and examination best done

with the parent out of the room, parental
presence during painful procedures is normally a
helpful adjunct.
PHARMACOLOGIC ANXIOLYSIS
Benzodiazepines (midazolam) are used for anxiety short duration of
action.
dose of midazolam
0.5 mg/kg PO
0.05 to 0.1 mg/kg IV
onset of action is roughly 20 minutes
can also be given nasally at 0.2 mg/kg, and has an even shorter onset of
action, but the acidic properties may cause some local nasal irritation.
Oral midazolam seems to have a longer duration of effect than when given IV

Higher doses
respiratory depression and even arrest
small number of children can exhibit a paradoxical reaction with agitation,
confusion, or crying
Reverse with flumazenil
Flumazenil has a shorter duration of action than midazolam, so

respiratory depression may theoretically reoccur as flumazenil wears

off
ANALGESIA
TOPICAL ANESTHETICS
minimize the pain of venipuncture and IV
catheterization
EMLA and LMX

EMLA
eutectic mixture of prilocaine and lidocaine
onset of action is 30 minutes
LMX
liposomal lidocaine, are both fat-absorbable cream
preparations that produce anesthesia of the skin
surface
20 to 30 minutes
LOCAL ANESTHETICS
most commonly lidocaine
4mg/kg (block)
SYSTEMIC ANALGESIA
newborns and infants
oral sucrose in a 25% solution offered on a pacifier dipped into the solution just
before the procedure
Ketorolac is an injectable NSAID
effective
for musculoskeletal pain and the pain of renal lithiasis and ovarian
pathology.
Dose, 1 mg/kg IM or 0.5 mg/kg IV
Opiates
moderate and severe pain
choice of parenteral opiates should be determined by the individual
characteristics of the drug, as well as the specific clinical indication
Fentanyl
histamine release than the nonsynthetic opioids and has a relatively short duration of action
If given as a rapid IV bolus, or in high doses, to younger patients, it can cause rigid chest

phenomenon
reversal with naloxone or neuromuscular blockade.

Hydromorphone - higher potency than morphine

Meperidineis not recommended for use in children
Drug IV Dose Onset Duration Side Effects
Morphine 0.10.3 510 14 h Histamine release/pruritus
mg/kg min
Seizures in neonates

Nausea
Hypotension
Hydromorphone 0.0150.020 510 14 h Nausea
mg/kg min Pruritus
Fentanyl 12 mcg/kg 12 3060 min Bradycardia
min Respiratory depression
(outlasts analgesic effect)

Chest wall rigidity (risk

increases with larger doses
SEDATION
 INDICATION
Indications Examples

Very painful procedures of any length Reduction of fracture

Moderately painful protracted Incision and drainage of subcutaneous

procedures abscess

Extreme anxiety or developmental Autistic, developmentally delayed, 55-

barriers when attempts at anxiolysis kg 14-year-old with simple arm
have failed laceration

Need for complete motionlessness Repair of laceration of the eyelid in a

toddler
 ANXIOLYTIC
Drug Dose Onset Duration Advantages Disadvantages Example Comment
Midazolam PO/PR PO/PR 2030 14 h Flexible route No analgesia, Premedicatio Acidic, nasal
0.5 mg/kg min of paradoxical n for IV administratio
administration reaction start, n stings, may
IV/IM IV 1 min laceration cause
0.1 mg/kg repair using increased
IM 510 min local secretions;
anesthetic oral/rectal
slow onset,
less
predictable,
paradoxical
reaction
treated with
flumazenil,
0.02 mg/kg
 HYPNOTIC/SEDATIVE
drug Dose Onset duration Advantage disadvantage Example comment

Propofol 12 mg/kg IV Seconds Minutes Rapid onset and No analgesia, CT scan, LP Nonanalgesic,
short duration, respiratory and with topical increased
motionlessness, cardiovascular analgesic, requirement
muscle relaxant depressant laceration for younger
repair, patients,
reduction of painful
dislocation injection
Etomidate 0.10.3 Seconds Minutes Rapid onset, No analgesia, CT scan, short Avoid in
mg/kg IV short duration myoclonus, procedures patients with
respiratory requiring increased tone
depressant motionlessness (e.g., CP) due
to myoclonic
jerks, painful
injection
Pentobarbital 25 mg/kg IV <1 min 3090 min Well studied, No analgesia, CT scan, no Variable
motionlessness, respiratory and reversal agent dosing, long
neuroprotective cardiovascular recovery times
depressant
Methohexital 1 mg/kg IV Seconds 1090 min Rapid onset No analgesia, CT scan, no
respiratory and reversal agent
cardiovascular
depressant
 DISSOCIATIVE
drug dose onset duration Advantage Disadvant Example comment
age
Ketamine IV IV 12 min IV 10 min Analgesic, Increased Painful Pretreat with
1 mg/kg anesthetic, intraocular procedures ondansetron;
IM 35 min IM 3045 motionlessness pressure, requiring atropine and
IM min , respiratory intracranial motionlessn midazolam
4 mg/kg and pressure, ess coadministrat
cardiovascular salivation; (complex ion
stimulant, emetogenic; lacerations, controversial
bronchodilator laryngospasm fracture
reductions,
I & D), no
reversal
agent
 COMBINATION
drug dose onset duration Advantage Disadvanta Example comment
ge

Fentanyl + Fentanyl 12 12 min 13 h Analgesic and Respiratory Fracture Reversal with

midazolam mcg/kg anxiolytic depressant reduction, flumazenil and
reduction of naloxone
midazolam dislocation,
0.050.1 mg/kg laceration
repair
Propofol + Propofol 12 1 min Propofol Decreased Fracture Consider
ketamine mg/kg (minutes); dosing for both reduction, I & ondansetron
ketamine 15 agents, D, complex
ketamine 0.3 45 min antagonistic laceration
0.5 mg/kg side effects
(lessens
respiratory
and
cardiovascular
depression,
emesis)
THANK YOU