SCOPE OF THE PROBLEM

Procedural sedation and analgesia (PSA) in the emergency department (ED) is a common component of the modern practice of emergency medicine. The concepts inherent to PSA, however, are not new to emergency care for the sick and wounded.

Medical accounts from authors as early as Hippocrates have included descriptions of painful procedures, such as orthopedic dislocation and fracture reduction, in their accounts of the stabilization of patients with acute medical and traumatic conditions. Along with these descriptions, physicians have often described the use of certain techniques or adjuncts to assuage the pain associated with therapeutic procedures.

Historical depictions of procedure patients have frequently included images of caregivers providing alcohol or inhalational agents to alleviate procedure-related pain and suffering. These concepts have become inherent to our collective view of the role of medical caregivers as both prescribing treatment as well as relief of pain and suffering throughout history.

The rationale for administration of analgesic and/or sedative agents has generally relied upon the reduction of pain and suffering. Modern medical practice recognizes the importance of PSA as being equally important for the provision of a number of additional elements including relaxation of affected muscle groups and tissues adjacent to injured structures, reduction of patient anxiety, and as a means to improve the broad experience of the procedure encounter not only for the patient but also for patient family members and health-care providers alike.

SCOPE OF THE PROBLEM

Pain is the presenting complaint for up to 70% of visits to the emergency department (ED). There are a myriad of strategies to treat and diagnose pain. The effective strategies are those with adequate and timely pain relief without adverse effects.

In 1992, the World Health Organization developed a clinical guideline for the treatment of acute pain. This guideline includes basic instructions to select an appropriate pain medication for the patient's pain intensity, individualize the dose by titration of opioids, and concomitantly provides adjuvant analgesic drugs as co-analgesics or to counteract side effects.

It has been shown that patients frequently receive inadequate analgesia in the ED. Oligoanalgesia, the inadequate treatment of pain, frequently occurs in the ED, especially in those patients at the extremes of age and members of minority and ethnic groups.

Treatment of pain is essentially a simple process, and a wide variety of agents and techniques are available that are generally effective. Morphine has been recognized as a basic treatment for pain throughout the modern era of allopathic medicine. It is effective, easy to obtain, and has never been expensive. However, morphine has severe side effects when overused, specifically in the acute setting with respiratory depression, hypotension, and a decreased ability to report worsening symptoms. Issues with the chronic use of morphine, as with all opiates, include suppression of the endorphin system with associated vegetative changes and physiologic dependence.

SCOPE OF THE PROBLEM

All chronic pain begins as acute pain. The physiologic transition from acute to chronic pain syndromes results from physiologic and psychosocial transitions that are not well defined. Generally speaking, acute pain becomes chronic pain when the physiologic insult that caused the original pain has resolved or reached a static or progressive state.

A large number of emergency department (ED) patients have underlying chronic pain syndromes. It is very common in the U.S. population, with rates as high as 40% noted in one review.

The key step to the prevention of chronic pain may be the adequate treatment of acute pain. Acute pain serves an adaptive purpose in that it stimulates protection of the injured area via recruitment of tissue repair mechanisms as well as physiologic responses such as increased blood pressure and respirations. As the injury heals, these adaptive purposes become maladaptive, as limited movement causes a decreasing range of motion, prolonged stress response causes impaired immune response, hypercoagulable states, and vegetative symptoms (Table 21-1).

It can be difficult to determine at what point pain changes from adaptive to maladaptive, or from acute to chronic. Acute and chronic pain call for different treatment approaches, both in terms of the approach to the patient and to the medications used. The maladaptive components of chronic pain can push patients toward behaviors that can hinder their recovery (lack of abnormal use of painful extremities, inactivity) and impact their mood, social interactions, and lifestyle (Figure 21-1).

SCOPE OF THE PROBLEM

The closed reduction of fractures and dislocations presents an excellent situation in which to perform procedural sedation. Fracture and joint reductions involve a great deal more pain than the patient feels prior to or after the reduction. Procedural sedation should provide analgesia prior to and during the procedure, sedation, muscle relaxation, and procedural amnesia for these painful events. Proper sedation for these procedures has the additional benefit to the medical care provider(s) by optimizing patient relaxation to facilitate a successful reduction.

Once a reduction has been completed, patients often have less pain than prior to the procedure owing to stabilization of the bone or joint. The use of long-acting sedative agents for procedural sedation, in combination with long-acting analgesics, may lead to patients who have unnecessarily extended periods of sedation particularly following the procedure when stimulus and pain are minimal. Such an extended period may lead to respiratory depression at a time when patient monitoring has been reduced. This concern, in addition to caregiver desires to shorten procedural sedation times in order to reduce the period of moderate or deep sedation and the duration of extensive staff patient monitoring, has led to significant changes in medical practice in favor of short-acting sedation agents.

CLINICAL ASSESSMENT

Both the urgency of the patient's requirement for fracture or joint reduction and the patient's current and preexisting medical conditions must be considered prior to procedural sedation.