Tackling The Most Commonly Abnormal ED "Vital Sign"

The Gist:  Pain is subjective and ubiquitous in the emergency department (ED).  Treatment of pain in the ED varies widely between practitioners and is often not formally taught as part of the curriculum, lending this aspect of EM to often be characterized as "art."  I came up with a rough pain control algorithm for acute pain or recurrent pain as I get started in Emergency Medicine, roughly based on an evidence based template from Lipp et al (note: I'm not an expert and this is far less useful for complex pain complaints such as migraine and does not address procedural sedation).

Check out this article by Dr. Leon Gussow of The Poison Review on the darker side of the emphasis of pain as a Joint Commission mandated vital sign in the ED.  

Regional Analgesia - It appears that, with the aid of ultrasound, nerve blocks are increasingly common in the ED. These are great for orthopedic and soft tissue injuries, and there seems to be a movement to increase utilization for hip fractures (Haslam et al, Haines et al)

Upsides:   Patient may not need sedation or sedating analgesics, thereby preserving mentation, respiratory drive, and hemodynamics.  Great, targeted analgesia 

Downsides: Potentially time consuming, invasive, disrupts neuro exam, potential for systemic toxicity (use ultrasound!).  

Pearls: 

• Practice these on an anesthesia rotation. 
• Use ultrasound:  Ultrasound Guided Nerve Block Education, Part I, Part II, Femoral Nerve Blocks, Sonoguide.com.  Sonospot.com has many useful posts on publications and tipstricks for ultrasound guided nerve blocks (searchable).
• Perform a solid neurovascular exam before performing the block.  Monitor patients afterward. 
• Work with consultants (ex: ortho for blocks for femur and hip fractures).

Non-opioid Analgesics - Acetaminophen (APAP) and Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for mild to moderate pain (2).

Upsides:  NSAIDs are especially useful in prostaglandin-potentiated conditions, such as dysmenorrhea, gout, rheumatoid arthritis, and ureteral colic (1, 2).  APAP is safe in pregnancy (1,3).

Downsides: 

• Dose-limiting adverse effects on the gastrointestinal tract (NSAIDS). Must be cognisant of total APAP load across all medications so 4g/day is not exceeded  (1,2).
• NSAIDS may have untoward effects in patients on other medications including: warfarin (bleeding), diuretics/lithium/ACE-I/methotrexate (renal insufficiency and subsequent therapeutic index issues) (1).
• NSAIDS may induce or worsen renal insufficiency in elderly patients, those with pre-existing renal disease, or in the setting of dehydration (3).

Pearls:

• Ceiling dose for analgesia from ibuprofen lies in a 400mg dose (higher ceiling dose for anti-inflammatory effect), discussed in this blog post by Dr. Chris Bond. 
• Parenteral keterolac offers no better analgesia compared with ibuprofen or naproxen, and costs much more (Dr. Bond's post, Arora et al, 2, 4).
• IV APAP, used internationally with success, has made an appearance in the US over the past couple of years, but comes at a cost of more than $10 USD per 1g dose without drastically better analgesia.  The focus on IV APAP is the potential opioid sparing effect (Kwiatkowski et al)

Opioid Analgesia - These get the most attention in the ED, partially due to the focus on abuse.  There are many drugs in this category but they tend to fall into groups:  

• Opiates (derived from the opium plant) - morphine, codeine
• Semi-synthetics - hydrocodone, oxycodone, hydromorphone, oxymorphone, buprenorphine, heroin 
• Synthetics - fentanyl, alfentanil, sufentanil, remifentanil, methadone, tramadol, propoxyphene, meperidine

Upsides: 

• Good analgesia for visceral and somatic pain
• Many opioids are titratable

Downsides:  

• Respiratory depression
• Histamine release - pruritus, flushing, hives, and/or hypotension.
• Released from mast cells, may be mistaken for allergic reaction (which has an immunologic component). 
• Opiates tend to cause more histamine release than the semi-synthetics and synthetics (6).
• Potential for abuse/dependence

Pearls:

• IV morphine starting dose for moderate-to-severe pain = 0.1 - 0.15 mg/kg. 
• Patients in severe pain or opioid-tolerant, will not obtain adequate analgesia with a single 0.1-mg/kg dose and may require additional doses.
• Oral opioids (hydrocodone) may take 30-60 min to achieve analgesia (3). 
• This may be off-set by time to establish an IV, etc (Miner et al)
• Oxycodone starting dose 0.125 mg/kg (Miner et al) in most patient populations.
• IV hydromorphone starting dose 1mg, with an additional 1mg dose if analgesia not achieved (5).
• less renal clearance so may be better in patients with renal insufficiency (2,4)
• less histamine release (6).
• When discharging a patient home with opioids, consider checking the state monitoring program online (ACEP clinical policy, Level C).  This can be time consuming and is generally limited to a single state.  Listen to Dr. Scott Weingart's Practical Evidence podcast on this.
• When prescribing, prescribe a short course (ex: 3 days).
• It's widely accepted that analgesia doesn't "mask" surgical pathology, which was a historic concern in patients with suspected intra-abdominal pathology (1-4).

Poppies in Turkey

References:

1.  Miner J, Paris P, Yealy D.  "Pain Management."  Rosen's Emergency Medicine.  7th ed. p 2410-2428.  
2.  Lipp C, Dhaliwal R, Lang E.  Analgesia in the emergency department: a GRADE-based evaluation of research evidence and recommendations for practice.  Critical Care 2013, 17:212 
3.  Ducharme, J.  "Acute Pain Management in Adults."  Tintinalli's Emergency Medicine.  7th ed.  p 259-265.

4.  Heins, Alan. Focus On: Effective Acute Pain Management.  October 2005.  ACEP. 

5.  Chang AK, et al. Randomized clinical trial of the 2 mg hydromorphone bolus protocol versus the "1 + 1" hydromorphone titration protocol in treatment of acute, severe pain in the first hour of emergency department presentation. Ann Emerg Med. 2013 May 16. 

6.  Li, F.  Pharmacologically Induced Histamine Release: Sorting Out Hypersensitivity Reactions to Opioids 

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...)