Pain Management

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Associate Professor Peter Manning Emeritus Consultant Emergency Medicine Department National University Hospital, Singapore

Jan 2004

Revised Aug 07 / Feb 08 / Nov 09 / Dec 11 / Dec 12

Accepted practice patterns must be questioned – implementation of pain score to vital signs

We underestimate the pain produced by common practical procedures

Analogy – just as we vary antibiotics according to sensitivities, perhaps we should be prepared to be more flexible with our pain management

We will discuss:
1.Management of acute pain in the EMD emphasizing various clinical scenarios 2.Procedural sedation (a.k.a conscious

sedation) 3. Management of chronic pain in the EMD


(Wilson JE, Pendleton JM. Oligoanalgesia in the
Emergency Department. Am J Emerg Med 1989;7620-623) “OPIOPHOBIA” [Sergey M. Motov & John P. Marshall. Acute Pain Management Curriculum for Emergency Medicine Residency Programs. Academic Emergency medicine 2011; 18:S87-S91]

Why is this so when we see plenty of
people in pain? – it is, after all, the commonest presenting symptom at the


Early and appropriate management of pain is
important because : • patients become increasingly more sensitive to painful stimulus the longer the pain is uncontrolled – a process called “wind-up” • interventions before “wind-up” occurs can potentially decrease subsequent pain and analgesic requirements

• incomplete pain relief should be the choice of the
patient, not the physician

“Whose pain is it anyway?”

Pain is a major cause of partial or total disability in
industry – it has astonishing economic implications in terms of healthcare utilization and lost wages

How would you manage

PAIN in the following conditions
that are frequently encountered in the ED ?

Scenario 1

Scenario 2

Scenario 3

Scenario 4

Scenario 5

Scenario 6

Scenario 7

Scenario 8

Scenario 9

Scenario 10

Scenario 11

Overview of Pain Management in ED
RICE •Rest •Immobilisation •Cold / Compression •Elevation Dressing Parenteral Pharmacological Non-parenteral

Blocks : RA, LA

Scenario 1 Distal radial fracture
Treatment - ?


Choice: Bier’s Block (Intravenous Regional Anaesthesia – IVRA) Suitable for any procedure inc. M&R on wrist and distal forearm

Bier’s Block
Contraindications • Uncooperative • Too young : < 10 yrs or < 25 kg • Medical history : epilepsy, severe hypertension, severe peripheral vascular disease • True allergy to lignocaine Preparation • Past medical history • Targeted examination : baseline BP / CHF • ECG : for patients > 60 yrs • Explain procedure to patient • Time out - IPSG # 4

Bier’s Block
Technique ?
• Patient in monitored area

• Monitors : cardiac monitor, BP, SpO2
• IV cannula in each hand – now controversial

• Apply tourniquet on affected arm : 50-100 mmHg above SBP • Do not forget protective under padding

Bier’s Block
Technique (cont’d) • Inject 0.5% lignocaine and note TIME Draw up 10 mls of 1% lignocaine with 10 mls NS (100mg in 20 mls) Toxic dose of lignocaine : 3 mg/kg (50kg adult = 150 mg) Adult : 20 mls Elderly : 15 mls Paeds : 10-15 mls

Blanching of skin is expected and is indicative of patchy vasoconstriction • Patient may c/o burning or ‘heat’ in the arm

Bier’s Block
Deflation • Do not deflate cuff if injection time is less than 20 mins  avoid high concentration of lignocaine potentially entering the circulation • Age-old technique NOT evidence-based Discharge • Observe x 2 hrs

• Check limb circulation……document it

Bier’s Block – possible complications
Lignocaine toxicity • Be able to recognize the signs & symptoms • circumoral numbness
• light headedness

• irrational conversation
• unconsciousness

• tinnitus
• visual disturbance

• grand mal seizures
• cardio-respiratory

• slurred speech
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