Background
Pain is commonly under-treated and treatment may be delayed. Recognition and alleviation of pain should be a priority when the treating ill and injured. This process should start at the triage, be monitored during their time in the ED and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge. The pain ladder contains objective and subjective descriptions with a numerical scale. The experience of the member of staff triaging will help in estimating the severity of the pain.
How to Manage Pain
- Patients in severe pain should be transferred to an area where they can receive appropriate intravenous (e.g. partacetamol / opiates / parecoxib) or rectal analgesia within 20 minutes of arrival
- Patients in severe pain should have the effectiveness of analgesia re-evaluated within 30 minutes of receiving the first dose of analgesia
- Patients in moderate pain should be offered oral analgesia at triage / assessment
- Patients with moderate pain should have the effectiveness of analgesia re-evaluated within 60 minutes of the first dose of analgesia
- Documentation of the above on the ED card is essential
*Other causes of distress include: fear of the unfamiliar environment, needle phobia, fear of injury severity etc.
Contra-indications
- Ibuprofen: avoid if previous reactions to NSAIDs or in moderate or severe asthmatics
- Diclofenac: Avoid in patients with heart failure, periph. art. disease or cerebro-vascular disease(↑ thrombotic risk similar to selective COX-2 inhibitors)
- IV opiates: use with caution if risk of depression of airway, breathing or circulation
Notes
- In all cases it is important to think of using other non-pharmacological techniques to achieve analgesia, which may include measures such as applying a dressing or immobilising a limb etc
- Following reassessment if analgesia is still found to be inadequate, stronger / increased dose of analgesics should be used along with the use of non-pharmacological measures
- It is important to re-assess the pain control within 30 minutes in severe pain and within 60 minutes in moderate pain
Pain |
Score |
Mx |
No pain |
0 | No action |
Mild pain |
1 - 3 | PO analgesia |
Moderate pain |
4 - 6 | PO/IV NSAIDs |
Severe pain |
7 - 10 | IV opiates/NSAIDS or PR NSAIDs |