Pace 2014 Acute pain in ED

Information about Pace 2014 Acute pain in ED

Published on August 6, 2014

Author: drvenugopalpp

Source: authorstream.com

Content

Acute Pain Management in the ED: Acute Pain Management in the ED Dr. Venugopalan P.P. DA, DNB, MNAMS.MEM[GWU-US] Director ,Emergency Medicine ,Aster-DMHC Deputy Director ,MIMS Academy Site Director and National Faculty ,Masters program in EM,GWU USA Founder &Executive Director ,ANGELS Kozhikode , Kerala , India www.drvenu.net Introduction: Pace 2014,August 2014 -1 to 3 rd at Chennai Introduction Pain is the most common presenting symptom in emergency departments More than 60 percent of ED patients have pain as their main symptom or a major part of their symptoms. Introduction…: Pace 2014,August 2014 -1 to 3 rd at Chennai Introduction… Pain is always subjective . No test to prove or disprove the patient’s pain. Not vital signs, a patient’s facial expressions, or “gut instincts” can be used to invalidate a patient’s rating of his or her pain. Introduction…: Pace 2014,August 2014 -1 to 3 rd at Chennai Introduction… An unrelieved pain has deleterious effects on “physical, physiological & psychological” systems. Remarkable discomfort to the patients Introduction…: Pace 2014,August 2014 -1 to 3 rd at Chennai Introduction… International accreditation agencies like JCAHO are setting standards in management of pain in emergency departments. Focus : Pace 2014,August 2014 -1 to 3 rd at Chennai Focus Define acute pain Brief overview of pathophysiology Barriers in pain management in ER settings Common Dos & Don'ts Strategies to improve pain management in ER Definition: Pace 2014,August 2014 -1 to 3 rd at Chennai Definition Pain is ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’ or, more simply, ‘pain is what the patient says it hurts’ Assessment of acute and chronic pain, www. Anesthesiauk.com Created: 5/9/2005 ,Updated: 12/1/2009 PowerPoint Presentation: Pace 2014,August 2014 -1 to 3 rd at Chennai Sensory Emotional Cognitive Behavioral Environmental Developmental Socio-cultura l Contextual PAIN PowerPoint Presentation: Pace 2014,August 2014 -1 to 3 rd at Chennai A C U T E C H R O N I C Somatic ,Visceral or Neuropathic PAIN Acute pain: Pace 2014,August 2014 -1 to 3 rd at Chennai Acute pain Injury or Pathologic condition Resolves with inciting cause Nociceptors Release of chemicals – leukotrienes, Bradykinins, Serotonin, Histamine & Thromboxanes Prostaglandins: Pace 2014,August 2014 -1 to 3 rd at Chennai Prostaglandins Not directly activate receptors Act as local mediator Increases sensitivity of nerve endings Pain and edema Fink WA Jr, The pathophysiology of acute pain .Emerg Med Clin North Am. May 2005;23[2]:277-284.[review] PowerPoint Presentation: Pace 2014 ,Chennai August 1 to 3 rd Acute Pain Video on Pain perception: Video on Pain perception Pace 2014 ,August 1-3 at Chennai PowerPoint Presentation: Pace 2014 ,August 1-3 at Chennai Non – Noxious Stimuli Non – Noxious Stimuli Pain Pain Nociceptive Pain Neuropathic Pain Neuroplastic Pain Tissue Injury Tissue Injury Nerve Injury Pain Nociceptive pain –Video : Nociceptive pain –Video Pace 2014 ,August 1-3 at Chennai Pain should be treated as early as possible: Pace 2014 ,August 1-3 at Chennai Pain should be treated as early as possible Noxious stimuli cause increased nociceptor responsiveness Progressive increase in dorsal horn neuron output Pain amplification “Wind up” phenomenon Sharp localized pain Dull diffused pain When a patient in pain enters the ED he or she has two main concerns : Pace 2014 ,August 1-3 at Chennai When a patient in pain enters the ED he or she has two main concerns 1.How quickly can I get relief from my pain?      2.What is causing this pain? The major focus of health care professionals : The major focus of health care professionals 1. What is the diagnosis?       2. What is the treatment for the underlying disease process? Pace 2014 ,August 1-3 at Chennai PowerPoint Presentation: Pace 2014 ,August 1-3 at Chennai Pain Assessment Management PowerPoint Presentation: Pace 2014 ,August 1-3 at Chennai No Pain Worst Pain Imaginable Visual Analogue Scale The patient is shown a 10cm line marked as above. They are asked to put a mark across the line that indicates the severity of the pain. Doctor or Nurse then measure the distance from “No pain “ to the mark in cm PowerPoint Presentation: Pace 2014 ,August 1-3 at Chennai 0 1 2 3 4 5 6 7 8 9 10 No Pain Worst Pain Imaginable Numerical Analogue Scale The patient is shown the scale above. They are asked to indicate which number equates to the pain they feel Verbal Rating Scale -VRS: Pace 2014 ,August 1-3 at Chennai Verbal Rating Scale -VRS Five pain levels in large print No pain Mild Moderate Severe Unbearable Verbal Descriptor Scale : Pace 2014 ,August 1-3 at Chennai Verbal Descriptor Scale No pain Mild Discomforting Distressing Horrible Excruciating [Tanabe] Pain assessment in children: Pace 2014 ,August 1-3 at Chennai Pain assessment in children Wong-Bakers FACES – Pain Rating Scale Hockenberry MJ: Essentials of pediatric Nursing ed 7,st,Louis ,2005 ,Mosby P 1301 CHOEPS Children’s Hospital of Eastern Ontario Pain Scale: Pace 2014 ,August 1-3 at Chennai CHOEPS Children’s Hospital of Eastern Ontario Pain Scale Crying Facial expression Verbalization Activity of Torso Touching Response of Lower limbs Score Minimum – 4 Maximum - 13 Hennrikus:J Bone Joint Surg Am ,Volume77-A[3] March 1995.335-339 PQRST Symptom Analysis : Pace 2014 ,August 1-3 at Chennai PQRST Symptom Analysis P resentation , P rovocation & P alliative Q uality – Sharp, Dull ,Pricking ,colicky etc R adiation, R egion and R elieving factors S everity – Pain Scale T ime of onset and T reatment received Methods to relieve acute pain : Pace 2014 ,August 1-3 at Chennai Methods to relieve acute pain Splinting Cold pack Positioning Relaxation techniques TENS Incentive spirometer Acupuncture Non Pharmacological Methods to relieve acute pain: Pace 2014 ,August 1-3 at Chennai Methods to relieve acute pain Acetaminophen NSAID Opioids Antidepressants Steroids Anticonvulsants Entonox Ketamine Procedural Sedation Pharmacological Nerve blocks PowerPoint Presentation: Pace 2014 ,August 1-3 at Chennai Brain Arachidonic acid Spinal cord NSAIDS Prevention Peripheral Nerve Nociceptor ‘Sensitizing soup’ prostaglandin Physical Stimulus [Heat, Pressure] Opiates Alpha 2 agonists Local Anesthetics Tissue injury Analgesic Therapy Simple model : Pace 2014 ,August 1-3 at Chennai Simple model ‘Assessment –Treatment- Reassessment’ “Diagnosis and Treatment” of the underlying condition Pain relief T I T R A T E PowerPoint Presentation: Pace 2014 ,August 1-3 at Chennai OPIOIDS regularly Paracetamol 1gm orally or rectally /regularly q. d.. s Severe pain Moderate pain Mild pain OPIOIDS when required Non steroidal anti inflammatory drugs 0 3 6 10 No Pain Moderate pain Worst Possible pain Acute pain relief Treatment Chart PowerPoint Presentation: Pace 2014 ,August 1-3 at Chennai Mild pain 1-3 Paracetamol p.o Ibuprofen p.o Moderate pain 4-6 As for mild pain + NSAIDS p.o or Tramadol p.o Severe pain 7-10 Entonox initially or IV morphine Titrated Dose Supplimented with NSAIDS or Ketamine Assess pain severity Use Splints/Slings/ Dressings Consider the other causes Consider regional blocks Acute pain treatment algorithm Pain is under treated !!: Pace 2014,August 2014 -1 to 3 rd at Chennai Pain is under treated !! Evidences : Pace 2014,August 2014 -1 to 3 rd at Chennai Evidences Patients presenting to an ED with a complaint of pain, two-thirds never had an assessment of their pain documented. Todd KH et al. The Joint Commission on Accreditation of Healthcare Organizations Pain Initiative: Are We Meeting the Standard?   Annals of Emergency Medicine . 2000. 36:4 S68 Evidences… : Pace 2014,August 2014 -1 to 3 rd at Chennai Evidences… Of these patients, only one-third ever had a re-assessment of their pain Upon discharge from the ED, 43 percent of patients were still in moderate or severe pain Todd KH et al. The Joint Commission on Accreditation of Healthcare Organizations Pain Initiative: Are We Meeting the Standard?  Annals of Emergency Medicine . 2000. 36:4 S68 Evidences : Pace 2014,August 2014 -1 to 3 rd at Chennai Evidences Reviewed 198 patients admitted to ED with acute pain 67% had documentation 44% received narcotics 60% received intramuscular doses Wilson JE et al .Oligoanalgesia in the emergency department .An J Emerg Med .Nov1989;7[6]:620-623[Review 198 patients] Evidences…: Pace 2014,August 2014 -1 to 3 rd at Chennai Evidences… 33% of the documented cases received suboptimal analgesia 69% waited more than one hour to get analgesics 42% waited more than 2 hours. Wilson JE et al .Oligoanalgesia in the emergency department .An J Emerg Med .Nov1989;7[6]:620-623[Review 198 patients] Evidences…: Pace 2014,August 2014 -1 to 3 rd at Chennai Evidences… 842 patients at 20 US Canadian hospital participated in study to assess the current state of ED pain management. Patients presented with a median NRS of 8 Knox H .Todd; Acute pain in the emergency room setting : An expert interview; Medscape neurology & neurosurgery 05/27/2008;www.medscape.com Evidences…: Pace 2014,August 2014 -1 to 3 rd at Chennai Evidences… 41% - no change in the pain score in ED 34% -discharged without any change in pain score 45% patients discharged with NRS 4-7 and 29% patients with NRS 8-10. Knox H .Todd; Acute pain in the emergency room setting : An expert interview; Medscape neurology & neurosurgery 05/27/2008;www.medscape.com Acute Pain- The “ TRUTH”: Pace 2014,August 2014 -1 to 3 rd at Chennai Acute Pain- The “ TRUTH” The Fifth Vital sign Relief from pain is a “ Fundamental Right” “Declaration of Montreal”2010 Under assessed Under managed Emergency Department ANZCA .statement on pateints’ rights to pain management .ANZCA ps 45;2001,available at www.anzca.edu.au What are the barriers ?: Pace 2014,August 2014 -1 to 3 rd at Chennai What are the barriers ? Related Health Care system Health Care provider Patient Agency for Healthcare Research and Quality .[2005] Management of cancer symptoms :Pain, depression and fatigue .www.ahrq.gov/downlods/pub/evidence Pain B A R R I E R S Emergency Department Healthcare system related barriers: Pace 2014,August 2014 -1 to 3 rd at Chennai Healthcare system related barriers Lack of time ED overcrowding Poor levels of clinician education Inadequate policy and standards Suboptimal use of analgesics Martin D et al .Barriers to pain management in emergency department ; emergency nurse ,vol 15 no 9, feb 2008. 30-34; Healthcare provider related barriers: Pace 2014,August 2014 -1 to 3 rd at Chennai Healthcare provider related barriers Subjective nature of pain Attitude Beliefs Poor understandings / false beliefs on using opiates like morphine World Health Organization [1986]Cancer pain relief .WHO. Geneva Patient related barriers : Pace 2014,August 2014 -1 to 3 rd at Chennai Patient related barriers Misconceptions Society’s traditional views Fear of consequences Fatalism Communication fear Alcohol and drugs Martin D et al .Barriers to pain management in emergency department ; emergency nurse ,vol 15 no 9, feb 2008. 30-34; PowerPoint Presentation: Pace 2014, August 1-3 at Chennai Ten Do’s Ten Don’ts Ten’s ‘N’ Acute Pain P A I N Acute Pain – 10 – Do’s : Pace 2014, August 1-3 at Chennai Acute Pain – 10 – Do’s Believe the patient’s assessment of pain Give adequate doses of analgesics [ED & Disposal] and document the patient’s response Prevent pain before it begins Treat aggressively Titrate ...Titrate… Titrate… Acute Pain – 10 – Do’s…: Pace 2014, August 1-3 at Chennai Acute Pain – 10 – Do’s… 5. Opioids are very useful in both acute and chronic pain* 6. Anticipate side effects 7. Treat by the clock *Consensus statement ,the American Pain Society and the American Academy of Pain Management statement .Clinical journal of Pain . 1997.Mar.13[1]:6-8 Acute Pain – 10 – Do’s…: Pace 2014, August 1-3 at Chennai Acute Pain – 10 – Do’s… 8.Write prescriptions wisely [Quantity & Strength in both Letters and Numbers] 9.Refer patients appropriately to primary care provider or pain clinician 10.Prescribe Patient Controlled Analgesia [PCA] PowerPoint Presentation: Pace 2014,August 2014 -1 to 3 rd at Chennai Pain Sedation Analgesia Calls Nurse Nurse comes Nurse assesses pain Prepare injections Injection given Absorption Pharmacokinetics Variables Nurse variables Patient Variables PCA PCA S H O R T E N S The Cycles of Pain Control Acute Pain – 10 – Don’ts: Pace 2014,August 2014 -1 to 3 rd at Chennai Acute Pain – 10 – Don’ts Intramuscular injections Meperidine Sedative or anti-emetic along with analgesics Term ‘Narcotics’ Avoid…Avoid ..Avoid Acute Pain – 10 – Don’ts…: Pace 2014,August 2014 -1 to 3 rd at Chennai Acute Pain – 10 – Don’ts… 5. Codeine - Very weak opioids 6. Propoxyphene – Very weak analgesic 7. Treating acute and chronic pain in the same pace 8. Prescribing PRN schedule Avoid …Avoid…Avoid Acute Pain – 10 – Don’ts…: Pace 2014,August 2014 -1 to 3 rd at Chennai Acute Pain – 10 – Don’ts… 9. Holding Opioids due to fear 10.Holding pain treatment to reach a diagnosis. No need a ‘Diagnosis’ to control pain Silen W. Cope’s Early Diagnosis of the Acute Abdomen.2000 Acute Pain –Strategies : Pace 2014,August 2014 -1 to 3 rd at Chennai Acute Pain –Strategies Prioritize pain management Mandatory pain assessments Ongoing education- Patients & Clinicians Ongoing evaluation of strategies Rupp T et al , Inadequate analgesia in the emergency medicine. Annals of Emergency medicine 2004;43,4,494-503 International Guidelines: International Guidelines International guidelines : Pace 2014,August 2014 -1 to 3 rd at Chennai International guidelines Pain assessment standards [ Joint Commission on Accreditation of Health Care Organizations – JCAHCO 2001] USA JCAHO 2001.Revised pain management standards.www.jointcommission. org/standards/ International guidelines…: Pace 2014,August 2014 -1 to 3 rd at Chennai International guidelines… Musculoskeletal pain management guidelines [National Health and Medical Research Council -2003 ]-Australia Evidence- based management of acute musculoskeletal pain . www.nhmrc.gov/publications/ synopses/_files/cp94.pdf. 2003 International guidelines…: Pace 2014,August 2014 -1 to 3 rd at Chennai International guidelines… Recent guidelines [British Association for Accident and Emergency Medicine -2007] UK Clinical effectiveness committee audit standards for Emergency Departments. www.emergencymed.org.uk/BAEM/CEC/assets/summory_of_standards_Jan 2007. Conclusion: Pace 2014,August 2014 -1 to 3 rd at Chennai Conclusion Relieving from pain is the fundamental right of the patients. Physician’s lacunae should not end up in under treated pain . Conclusion…: Pace 2014,August 2014 -1 to 3 rd at Chennai Conclusion… International standards insist appropriate pain management protocols for ED setting. ER physicians should place and follow a pain free ER concept. PowerPoint Presentation: Pace 2014,August 2014 -1 to 3 rd at Chennai Thank You

Related presentations


Other presentations created by drvenugopalpp

Emerging emergency medicine
06. 08. 2014
0 views

Emerging emergency medicine

Copy of Acute pain in ED
06. 08. 2014
0 views

Copy of Acute pain in ED

Airway emergencies in oncology
20. 10. 2014
0 views

Airway emergencies in oncology

Niv in emergency department ebm
09. 11. 2014
0 views

Niv in emergency department ebm

Cricoid pressure : Yes or No
27. 03. 2015
0 views

Cricoid pressure : Yes or No

Pediatric BLS- Guidelines
19. 04. 2015
0 views

Pediatric BLS- Guidelines

FICB & Bier's block in ER
18. 03. 2016
0 views

FICB & Bier's block in ER

Poly trauma -initial evaluation
01. 08. 2017
0 views

Poly trauma -initial evaluation

Ima newsletter Volume 1
10. 07. 2017
0 views

Ima newsletter Volume 1

IMA News letter 2017
08. 07. 2017
0 views

IMA News letter 2017

Acute pain in ED NBE presenation
15. 08. 2017
0 views

Acute pain in ED NBE presenation

Emergency care mathrubhoomi
28. 09. 2017
0 views

Emergency care mathrubhoomi

Acute asthma  what is new?
11. 11. 2017
0 views

Acute asthma what is new?

Toxin and seizures
26. 11. 2017
0 views

Toxin and seizures

Poison intake and urgent care
14. 01. 2018
0 views

Poison intake and urgent care

End of Life Care -EoLC in ED
01. 02. 2018
0 views

End of Life Care -EoLC in ED

Glasgow Coma Scale : What is new
25. 09. 2018
0 views

Glasgow Coma Scale : What is new

Burns : pre hospital care
03. 12. 2018
0 views

Burns : pre hospital care