Analgesia Anaesthesia section



Assessment

  • Pain Score in isolation is NOT useful.
  • Need also to consider findings of catecholamine surge:
    • Raised BP, HR, RR, Sweating, Flushed, Nausea.
  • Distress is distress, perhaps (not always) secondary to pain.
  • Treat distress with appropriate small doses of anxiolytics and you will lower your analgesic requirement.
  • BUT… anxiolytics themselves are NOT a treatment for pain!
  • Different types of pain required different approaches:
    • Try to working out where the pain is coming from.

Establish an Analgesia Base

  • Paracetamol and NSAID (if not contraindicated) for all

Manage the Source of pain

Nociceptive Pain (i.e. Normal pain associated with acute injury/insult)

  • Epigastric Pain: PPI or H2 Receptor Antagonist (i.e. Zoton Fastab MADE IN IRELAND)
  • Cramping Pain: Hyoscine Butylbromide (Buscopam)
  • Is the patient constipated? (Movicol, Microlette, etc.)
  • Inflammatory Pain: (NSAIDs, or Steroids) ± Antihistamine
  • Bone / Muscle Pain: i.e. acute injury – see separate section
  • Nausea and Vomiting/ Retching Pain: NG tube ± Anti emetics

Neuropathic Pain (i.e. Chronic, abnormal processing of sensory input)

  • For chronic, please see Neuropathic Pain page
  • Assessment is important: Is this new pain because the patient is constipated? Gastritis? Injured?
  • Antidepressant and Anti-epileptics have role (has the patient recently stopped them?)
  • Is the patient still taking their Paracetamol + NSAID (i.e. baseline).
  • Better for the patient to be given Breakthrough pain relief and to see Pain Team in elective setting for objectivity.

When to reach for Strong Opiates (Morphine preparations)

  • In Acute Visceral Pain
  • ONLY once all of the above options have been utilised
  • Titrate to response

Managing Injuries in the ED

  1. Decide how you are going to TREAT the pain!
    1. Reduce, Splint, Cover or Irrigate?
  2. Analgesia Base
    1. Paracetamol + NSAID +- Simple opioid (codeine NOT Morphine).
    2. Procedural Analgesia and Sedation
      - See separate Sedation Policies for Adults and Children
      - Short acting opiates such as Fentanyl for the procedure itself ±
      - Short acting Hypnotic (e.g. See policy) or
    3. Regional Anaesthetic technique.
  3. Treat the pain
    1. Dislocations: Reduce.
    2. Fractures: Splint
    3. Burns: Cover from air.
    4. Irritant: Irrigate.
  4. Post Treatment Options:
    1. Maintain Analgesia Base.
    2. Consider Codeine/Paracetamol preparations (Solpadine 8/500 or Solpadol 30/500).
    3. Splinting/Strapping/Immobilise.
    4. Going to theatre/in-patient: Consider Long acting Opiate (Morphine).

Content by Dr Jason Van Der Veldt 03/11/2010. Last review Dr Íomhar O' Sullivan 19/06/18