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This chapter reviews the acute treatment process from evaluation and determination of the disease, which may or may not have a psychiatric origin, to stabilization. Psychosis is disruption in perception, organization of speech and/or organization of behavior. There are several disorders related to psychosis: brief psychotic disorder, schizophreniform, schizophrenia, severe mood disorders (depression or mania) with psychosis, schizoaffective disorder, delusional disorder, and shared psychotic disorder. Stabilization of the psychiatric patient in the emergency department (ED) depends largely on the presenting symptoms but can be thought of as having three main components: de-escalation, treatment, and evaluation of safety. De-escalation is needed for the agitated patient, to ensure safety. There are various treatment strategies for psychosis; the decision is based on several factors, such as patient preference, cost, and access to care. Disposition is largely determined on severity of illness.
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.
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.
Based upon their widespread effective use and reported results from meta-analysis of five RCTs, topical NSAIDs are the analgesic treatment of choice for traumatic corneal abrasions (CAs). There are no studies on the use of oral or parenteral NSAIDs in CA. Opioids have not been directly assessed as analgesics for CA. Oxycodone with acetaminophen (paracetamol) is useful as a rescue analgesic in patients failing topical NSAIDs. The ophthalmology literature makes frequent reference to the analgesic utility of bandage contact lenses in CA. However, this approach is not recommended for ED use since NSAIDs work well and the contact lens approach is associated with potential infectious complications, and limited study of cycloplegic use in CA is available. There has been limited study of cycloplegic use in CA. An RCT showed no benefit as assessed by either pain score improvement or need for rescue oral analgesics.
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.
Analgesia care in geriatric patients requires consideration of several age specific aspects of pain assessment and treatment. Geriatric oligoanalgesia is well known to occur in the acute care setting, and the problem has serious ramifications. Aging changes the physiology of drug absorption, distribution, metabolism, and elimination. Age-associated physiologic changes vary from patient to patient, in both degree and directionality. Opioid therapy provides an illustrative example of how altered elderly pharmacology dictates a conservative approach to analgesia titration. The Beers criteria have been adopted by many healthcare authorities, including the Centers for Medicare and Medicaid Services, and are now the most often-used consensus criteria guiding medication use in older adults. NSAIDs are widely prescribed, and frequently efficacious, in the acute care setting. Opioid selections for moderate (e.g. hydrocodone) or severe (e.g. morphine) pain in the elderly are generally similar to those for younger adults.
Marine envenomation can result from discharging nematocysts (e.g. jellyfish, fire coral), puncturing spines (e.g. sea urchins, stingrays), or actual bites (e.g. blue octopus, sea snakes). This chapter addresses jellyfish envenomation. The emphasis is on pharmacotherapy. Antivenoms (or antivenins) may be an option for some species of sea snakes, jellyfish, stonefish, and antivenoms are known to have rapid and profound effects upon pain. For jellyfish stings worldwide, the most useful topical agent appears to be acetic acid topically applied in the 4-5% concentration found in vinegar. Acetic acid controls pain by deactivating nematocysts, thus limiting continued envenomation from attached stinging cells. The proteolytic enzyme papain has historically been reported to relieve jellyfish sting pain. Hot water immersion and opioids are also recommended for pedicellarial stings from sea urchins. There are no data on use of NSAIDs for marine envenomation.