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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.

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

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.

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

A study ...

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