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  1. Home
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  3. Emergency Department Analgesia
  • Cited by 1
Publisher:
Cambridge University Press
Online publication date:
December 2009
Print publication year:
2008
Online ISBN:
9780511544835
DOI:
https://doi.org/10.1017/CBO9780511544835
Subjects:
Anesthesia, Intensive Care, Pain Management, Pathology and Laboratory Science, Emergency Medicine, Medicine
Series:
Cambridge Pocket Clinicians
Information

Book description

Nowhere in medicine is there a greater imperative to act than in the recognition and management of a patient's pain. This practical and evidence-based resource for emergency medicine and acute care providers will guide physicians in the selection of an effective therapy, define appropriate dosages to use and, equally important, when a treatment doesn't work, explain why, and what to do next. Starting with chapters on the assessment of pain, the safe and effective provision of analgesia in special populations, and featuring a reference table of drug names and interactions; the bulk of the coverage moves on to describe the provision of analgesia in the wide range of conditions likely to be encountered in the emergency department. The fundamental strengths of this approach are the comprehensive coverage, focus on practicality, basis in sound evidence, and authorship by specialists with extensive experience based on years of clinical practice.

Reviews

"Well-organized by disease state....an easy-to-use reference."
--Doody's Review Service

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Contents

Page 3 of 3

Contents
  • Postdural puncture headache
    pp 351-353
  • View abstract

    Summary

    The diagnosis of neuropathic pain (NP) encompasses a broad array of conditions. For the acute care provider, the goals of NP therapy are to decrease persistent pain and suppress breakthrough pain. One recommended strategy for NP treatment is to begin the therapy simultaneously with two drugs: an analgesic (e.g. mild opioid) and an adjuvant (e.g. antidepressant). Opioid doses in NP may be relatively higher than customary for non-NP indications, and in fact varying types of NP may warrant different opioid dosages. Clinically, patients with allodynia are potential candidates for local anesthetic use. Local anesthetics may also be useful in NP when administered in the form of regional nerve blocks. Since inflammatory mediators sensitize nociception, the anti-inflammatory corticosteroids have been used for NP. Corticosteroids also decrease local edema, thus reducing pressure on peripheral nerves. As dexamethasone has relative few mineralocorticoid effects, it is preferred by many who use corticosteroids in NP.
  • Post-herpetic neuralgia
    pp 354-358
  • View abstract

    Summary

    Acute care providers need to be familiar with phantom limb pain (PLP) as the complaint occurs in up to 80% of patients after amputation and it is important to institute early and effective intervention. Opioids are commonly recommended for acute treatment of PLP. Oral opioids, usually in combination with another agent (e.g. calcitonin), form the mainstay of PLP therapy. The benzodiazepines, which potentiate the spinal neuronal inhibitory effects of gamma-aminobutyric acid (GABA), may ameliorate pain from acute PLP flares. In contradistinction to their utility in other forms of neuropathic pain, antidepressants have only a limited role for acute PLP. The anticonvulsants have been investigated for PLP, with mixed results. Carbamazepine is postulated to be of utility, but supporting evidence for its use in PLP is anecdotal. There is stronger evidence for gabapentin prescription in PLP.
  • Renal colic
    pp 359-362
  • View abstract

    Summary

    This chapter addresses ocular inflammatory conditions such as conjunctivitis (allergic and infectious) and keratitis. For nearly all types of ocular inflammatory pain, ranging from traumatic inflammation to edema to allergic conjunctivitis, topical NSAIDs have proven useful. Topical NSAIDs also provide effective pain relief for allergic conjunctivitis. When corticosteroids are to be applied topically for infectious conjunctivitis, RCT evidence supports the use of dexamethasone. The historical role of cycloplegics in ocular conditions is based on their reduction of ciliary spasm-associated pain. Agents such as cyclopentolate are used in a variety of ocular inflammatory conditions, having been reported useful adjuncts for conditions ranging from keratoconjunctivitis-related ulcers to fungal iritis and plant sap-related conjunctivitis. The cycloplegics are particularly useful in traumatic or other etiologies of iritis, also contraindicated is the use of cycloplegics in patients with potential for angle-closure glaucoma.
  • Sialolithiasis
    pp 363-364
  • View abstract

    Summary

    Patients with odontogenic pain (OP) represent a broad spectrum of both disease etiology and severity. This chapter overviews the most important systemic, parenteral, and topical analgesic choices available to the acute care provider trying to relieve OP. NSAIDs are among the most widely used and well-studied drug classes used in management of acute and chronic OP, or odontalgia. Among the NSAIDs demonstrated to provide better pain relief than placebo is parenteral ketorolac. The mixed-mechanism drug tramadol provides pain relief that is partially mediated by opioid receptors. The supraperiosteal infiltration of local anesthetics usually provides suitable anesthesia when OP is emanating from a single maxillary tooth. Injection of local anesthetics is a legitimate, well-studied mechanism for providing relief of OP. In addition to its potential use in alveolar osteitis, benzocaine is efficacious in other causes of OP.
  • Sickle cell crisis
    pp 365-379
  • View abstract

    Summary

    While mechanical approaches (e.g. splinting) are important in managing sprain, strain, and fracture (SSF) pain, pharmacotherapy retains an important position for orthopedic analgesia. Systemic analgesics used for SSF include acetaminophen (paracetamol), NSAIDs, and opioids. This chapter focuses on systemically active analgesics. Pain relief for SSF can often be facilitated with local or regional injection of local anesthetics. Opioids have long been effectively used for severe SSF pain. Intravenous opioids (e.g. morphine) remain the most effective means for achieving both rapid analgesia and sustained relief (e.g. using patient-controlled analgesia) in most SSF conditions when combined with acetaminophen, the mixed-mechanism opioid tramadol is found to be equally efficacious to hydrocodone for relieving SSF pain. Many combination products are available and often include an opioid and a weaker analgesic such as acetaminophen or aspirin. However, few studies have rigorously evaluated their performance against alternative approaches such as opioid monotherapy.
  • Temporomandibular disorders
    pp 380-383
  • View abstract

    Summary

    Treatment of osteoporotic vertebral compression fracture (OVCF) is multifaceted, but most techniques (e.g. kyphoplasty, nerve blocks, jacket splints) require orthopedic consultation. For the acute care provider, OVCF pharmacotherapy begins with acetaminophen. The ability of opioids to alleviate OVCF pain is not doubted, although there is little high-level evidence addressing the subject. Meta-analysis of five RCTs evaluating calcitonin versus placebo for acute OVCF concluded that the drug significantly reduces pain, with an effect consistently identified within seven days of treatment. The reduction in pain score over that associated with placebo is both long-lasting and substantial. Like calcitonin, the bisphosphonates have been studied for bony tumor and cancer-related pain. There is less evidence addressing their use for OVCF. Given the relative strengths of evidence for calcitonin and the bisphosphonates, and the drugs' safety and side effect profiles, the authors recommend reserving pamidronate for situations where other approaches fail or are contraindicated.
  • Tension-type headache
    pp 384-388
  • View abstract

    Summary

    Given the frequency of otitis media (OM) and otitis externa (OE), there is surprisingly little evidence on treating pain associated with these conditions. For both conditions, there can be utility in mechanical interventions. The NSAIDs are typically recommended as first-line treatment, although evidence is sparse. Topically applied local anesthetics, generally benzocaine, are widely used for otalgia. A eutectic mixture of local anesthetics (EMLA), which contains lidocaine and prilocaine, is described as effective for relieving OE pain. Naturopathic topical approaches for OM are found by one investigator to be effective than the topical local anesthetic amethocaine. Trial evidence and reviews find neither antihistamines nor corticosteroids are effective in reducing OM pain. There are no data assessing otalgia relief for systemically administered opioids. However, expert panel evidence supports use of oral agents such as oxycodone or hydrocodone (usually in combination with acetaminophen or ibuprofen) for severe otalgia from either OM or OE.
  • Trigeminal neuralgia
    pp 389-391
  • View abstract

    Summary

    Opioids remain the most commonly used, and most commonly recommended, treatment for acute (and acute-on-chronic) pancreatitis. Most of the opioids are acceptable, there are reasons to select the mixed agonist-antagonist buprenorphine. Buprenorphine appears to have advantages related to paucity of effect on Oddi's sphincter. There is conflicting information as to the role of NSAIDs in treating pancreatitis pain. One expert consensus panel included NSAIDs as a first-line treatment for flares of chronic pancreatitis. The cholecystokinin (CCK)-receptor antagonists proglumide and loxiglumide appear to be effective in ameliorating pain from acute exacerbations of pancreatitis. One study demonstrated improvement in both subjective and objective (laboratory) parameters. Given potent inhibitory effects on pancreatic secretion, somatostatin and its analog octreotide have been studied for use in pancreatitis. Prophylactic somatostatin may reduce the rate of pancreatitis after endoscopic retrograde cholangiopancreatography. However, the acute care indications for this drug class are less clear.
  • Undifferentiated abdominal pain
    pp 392-397
  • View abstract

    Summary

    This chapter focuses on sore throat caused by viral or bacterial infection. It assumes that clinicians exercise appropriate precautions about airway management and possible complicating diagnoses. The NSAIDs, most commonly ibuprofen, are usually recommended for pain treatment of mild-to-moderate viral or bacterial pharyngitis (PG) in both adults and children. Aspirin, commonly dosed at 400-800 mg orally, is an effective PG pain reliever and is associated with symptomatic improvement. Acetaminophen is an effective reliever of mild pain, providing better PG relief than placebo within as little as 15 minutes. Corticosteroids, administered IM or PO in single or multiple doses, hasten the onset of both partial and complete pain relief in adults. In children, the utility of dexamethasone probably mirrors that of use of corticosteroids in adults with PG. Benzocaine (delivered by lozenges or spray) is commonly used for PG pain, but there are little applicable data for this indication.

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