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Emergency physicians are called upon to provide care for a variety of acute and life threatening conditions. Often patients present with pain as the primary symptom of their illness or require diagnostic and/or therapeutic interventions that are inherently painful to perform. As a result, the management of pain in the emergency department (ED) is a critical skill and an important element in the overall care of patients in emergency settings. This chapter provides an overview of acute pain in the ED as well as potential therapies, including regional anesthetic techniques for the emergency physician.
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EMERGENCY MULTIMODAL ANALGESIA
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Systems-Based Multimodal Approach
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The management of acute pain relies on providers and systems of care that are motivated, trained, organized, and equipped to rapidly treat acute pain. Without a clear organizational initiative and focus, pain treatment easily reverts to the low priority it has traditionally held in the emergency setting. Current understanding of the pathophysiology of pain suggests that opioids should preferentially be used only within a multimodal analgesic strategy tailored to the individual patient and his or her specific needs. Integrated use of complementary pharmacologic, interventional, and nonpharmacologic approaches enables the use of opioids that maximizes their beneficial properties while minimizing risk.
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Nonpharmacologic Interventions
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Effective treatment of the dislocated glenohumeral joint is prompt relocation. The underlying principle is that the ED should be organized so that simple, nonpharmacologic interventions such as elevation, icing, and immobilization of an acutely injured limb are prioritized from the point of triage. A humanistic approach with an outward expression of empathy and kindness can help to alleviate patient anxiety and fear.
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Identify Injuries and Conditions Appropriate for Regional Anesthesia at Triage
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Regional blocks should be placed as close to the time of initial injury as possible to maximize the potential of the block to limit the cascade of adverse physiologic events triggered by uncontrolled pain. Minimizing “door-to-block time” should be made a priority through collaborative systems development between emergency physicians and consultants.
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Nonsteroidal Anti-inflammatory Drugs
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Patients with severe acute pain should receive a nonsteroidal anti-inflammatory drug (NSAID) and acetaminophen unless contraindicated. Unfortunately, impaired platelet function and the risk of associated bleeding are of relative concern whereas nonselective NSAIDs should be avoided in the setting of acute trauma. An alternative strategy is the use of a selective cyclooxygenase-2 (COX-2) inhibitor such as celecoxib in combination with acetaminophen. Acetaminophen, although a relatively weak analgesic on its own, significantly enhances the analgesic effects of NSAIDs and opioids.
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Avoid a “One Size Fits All” Individual
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The dose response to opioids is notoriously variable. Rapid titration of relatively small doses every 10-15 minutes helps to both avoid overshooting the analgesic target and prevent oligoanalgesia.