FOAM: Fighting Oligoanalgesia And Meanness

The Gist:  Analgesia in the sickest emergency department  (ED) patients is inadequate, which is just plain mean.  Dr. Scott Weingart articulates it best in "Pain and Terror as Effective Pressors."  Adopt a protocol or algorithm to consider analgesia early on and with every patient.  If you have access to EBMedicine, check out their August 2012 summary on the trauma patient (subscription required).  They also have a great, free evidence based review of pain management as a whole in the ED.

Like most trainees I have a fear of patients taking advantage of my naiveity and started off wary of liberal analgesia. Stories of opioid abuse dotted medical and pop culture headlines. Clearly I didn't want to be oursmarted so I emulated others (and there is wide practice pattern variation among emergency physicians - Br J Anesthesia study).  I didn't realize this was problematic until,  early on in third year I was hanging out in the ED and an attending inquired, "2 mg of morphine? Do you want to piss on them or treat their pain?"  I was pretty mean.

Over the past year, however, I've noticed that I'm actually advocating for more analgesia from residents and attendings.  This is a result of influence by FOAM (EMCrit podcasts, an Annals audio summary, etc), and I first noticed a change in my practice when I saw something along the lines of:

•  A football player presented with his right hip flexed and internally rotated after a tackle went awry over an hour before.  It appeared shortened and the patient refused to move the leg.  Both extremities were neurovascularly intact and a quick AP of the hip and pelvis demonstrated a posteriorly dislocated hip.  The patient moaned in pain.  Procedural sedation with propofol was planned and the physician did not want to give opioids prior to the hopefully quick reduction due to hemodynamic and respiratory concerns (no ETCO2 used).  Eventually, the patient was given 4mg of morphine IV for analgesia after advocating for the patient.  The hip was reduced with significant effort under propofol, with respiratory depression requiring bagging. (An amazing piece on procedural sedation from St. Emlyn's)

Is this actually a problem?  Yes! Multiple studies corroborate this assertion, with good literature in trauma patients in the ED.  It's plausible that the run of the mill abdominal pain patient may experience oligoanalgesia in the ED, but the really sick and damaged patients?

• Neighbor et al study was a retrospective chart review of all Level 1 tier trauma patients over the course of one year. 
• n = 540 (excluded patients who received opioids solely within 10 minutes of chest tube placement or fracture manipulation) 
• Fewer than half of patients got IV opioids within 3 hours of arrival to the ED.  (n=258, 47.8%, 95% CI 43.5-52.1) 
• Average time to administration in those who received IV opioids = 40.1minutes  (+/- 41.1 min), 5 had prehospital IV opioids. This paper is predicated on the notion that proper analgesia in top-tier trauma patients must encompass IV opioids.  These were the highest acuity trauma patients, so these were not likely the folks that receive oral analgesics.
• The sickest patients (with the lowest Revised Trauma Scores) were less likely to receive analgesia.

Why don't we give adequate pain medications? There's a review in the Journal of Pain Research (free full text) that address many factors associated with oligoanalgesia in the ED.  Below are some I've encountered first hand.

We forget.  Emergency physicians are great under pressure, seamlessly MacGyvering difficult airways, obtaining hemostasis, and managing the chaos associated with 5-25 people in a cramped trauma bay while ensuring that all of the other ED patients remain stable.  Clearly, securing an airway and resuscitating a patient are crucial, but pain has physiological and psychological repercussions that can be deleterious as well. 

• From a purely (limited) anecdotal experience, I see patients undergo initial resuscitation and, after their whisked away to the CT scanner and some of the thrill has dissipated, never receive analgesia once they return to the ED.
• I include pain assessment/analgesia as part of my algorithm in patient assessment (and reassessments).  It takes little physician time and a protocol may help, as seen in this study.  A study by Chao et al in the Journal of Trauma demonstrated a mean time to administration of analgesia of 57 minutes.  There's probably time in there for some analgesia.

The patient doesn't complain of any pain.  If we ask for a pain level, one study sugggests that the patient is more likely to receive analgesia (Silka et al).

• Intubated and paralyzed patients.  It's hard to get them to quantify pain on a 10 point scale.

Weingart 19: take 2 fingers and jam them DOWN YOUR THROAT. This reminds you to treat your intubated with ANALGESIA. Fentanyl,opiod#acep12
— jeremy faust (@jeremyfaust) October 10, 2012

• The Neighbor et al study referenced above demonstrated that only 23.5% of intubated patients received opioids.  Probability = 0.40 (95% CI 0.30-0.53).  
• A study looking specifically at post-intubation analgesia showed that 53% of intubated patients (95% CI 44-62) received no analgesia after intubation (Bonomo et al).
• "Shell shocked" - For example, a mother involved in a car accident in which her children are also under treatment may be too emotionally wrecked to initially complain of pain.  Other individuals may have communication barriers that preclude pain complaints.
• If you intubate anyone, order analgesia when you set up your sedation and paralytics.  Again, Dr. Weingart spells it out here.

The patient is "too out of it" to feel pain.  The Neighbor study showed an association between low GCS and lack of IV analgesia.  Thirty patients with a CGS 9–13  received analgesia and of those with GCS 3–8, 13.5% received IV analgesia.

• In many of these cases, especially if there's some sort of head injury, an analgesic such as fentanyl may be somewhat protective against the catecholamine surge of intubation.  Check out Brian Lin's talk on intubation in head injury.

The patient is hypotensive. Hypotension in sick patients is bad (although "permissive hypotension" in trauma is another store, well explained on trauma.org here). There are some ways to work around and with this. 

• Per the EM/Critical Care guru, Dr. Weingart - start a pressor if you have to, but treat the patient's pain.  He advocates for a pain first algorithm in the post-intubation period on Podcast #21, preferentially, a fentanyl drip or an appropriate amount of morphine.
• Ketamine has analgesic properties, doesn't depress hemodynamic parameters, and is even fine in the head injured patient! Here's a good discussion of ketamine in the ED.   
• Consider nerve blocks in patients with isolated limb injuries (ex: hip fractures from the Emergency Ultrasound podcast). 

When I was tackled on that occasion, there were no injuries, but if I do end up in the ED-please give me adequate analgesia (do unto others...)