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Emergency physicians are called on to provide care for a variety of
emergent, urgent, and often complex conditions. Many patients present with
pain as a component of their illness or require diagnostic and/or
therapeutic interventions that are inherently painful to perform. As a
result, the management of analgesia in the emergency department (ED) is a
critical skill and an important element in the overall care of patients in
this setting. This chapter is an overview of acute pain in the context of
the ED as well as potential therapies, including regional anesthetic
techniques for the emergency physician.
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Pain is the single most common reason patients seek care in the ED, and
it accounts for up to 79% of visits.1 Given the
prevalence of pain as a presenting complaint, one might expect emergency
physicians to assign its treatment a high priority. However, pain is
seemingly invisible to providers of emergency medical care.
Oligoanalgesia, a term coined by Wilson and Pendleton2 in 1989, is the
inadequate use of methods to relieve pain. Multiple studies in the emergency
medicine literature have observed that oligoanalgesia is a common
occurrence.3 Notwithstanding the issue of providing
compassionate care, pain that is not acknowledged and managed appropriately
causes anxiety, depression, sleep disturbances, increased oxygen demands
with the potential for end-organ ischemia, and decreased movement with an
increased risk of venous thrombosis.4,5 Failure to
recognize and treat pain may also result in dissatisfaction with medical
care, hostility toward the physician, unscheduled returns to the ED, delayed
full return to full function, and a potential increased risk of
litigation.6
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Several studies have attempted to define the prevalence of pain and
oligoanalgesia in ED settings. Johnston and coworkers7
investigated the incidence and severity of pain among patients presenting to
noncritical treatment areas within the EDs of two urban hospitals in Canada.
Fifty-eight percent of adults and 47% of children reported pain on ED
arrival. Approximately 50% of these patients described the pain as
moderate to severe. At the time of discharge, one third of both groups
continued to report pain of moderate to severe intensity. In fact, 11% of
children and adults in this study actually reported clinically important
increases in pain intensity during their stay in the ED.
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Another prospective study found that among adults treated at one Chicago ED,
78% presented with pain as a chief complaint.8
Fifty-eight percent of all patients received analgesics or nonpharmacologic
intervention, but only 15% received opioids, despite high levels of pain
intensity. Guru and Dubinsky9 found that 50% of
patients who were treated for acutely painful conditions did not receive
prescriptions for pain management at discharge. Another review of urban,
university-based EDs reported that 69% of patients with painful
conditions, including thermal burns, long-bone fractures, and vaso-occlusive
crises, received no pain medication at all and that 55% were discharged
with no analgesic prescription.10
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