Emergency Sedation and Pain Management is a comprehensive medical textaddressing emergency sedation and analgesia with specific emphasis on treatment ofthe emergency department patient..
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Trang 3EMERGENCY SEDATION AND PAIN MANAGEMENT
Procedural sedation and analgesia represents one of the great advances in the maturation
of emergency medicine as a discrete specialty within medicine Once the exclusive domain
of the anesthesiologist, sedation and pain management procedures are now a routine part
of all emergency department practices
Emergency Sedation and Pain Management is a comprehensive medical textaddressing emergency sedation and analgesia with specific emphasis on treatment ofthe emergency department patient The easily accessible, clinically oriented formatallows the reader fast and efficient access to the key points in each chapter.The text presents a clinical approach to the treatment of pain in emergencypatients, including pediatric and adult populations Analgesia, sedation, andanesthetic techniques are presented in an informative, authoritative, and conciseformat – written and edited by physicians with extensive research as well as clinicalemergency medicine expertise The chapters are richly supplemented with tables,photographs, and step-by-step illustrations
j o h n h b u r t o n , m d, has been the Residency Program Director in EmergencyMedicine and a Professor of Emergency Medicine at Albany Medical College inAlbany, NY, since 2006 From 1999 to 2003, Dr Burton was the Medical Director forMaine Emergency Medical Services and, from 1995 to 2006, he worked in theDepartment of Emergency Medicine at the Maine Medical Center in Portland Hewas the founding Research Director in the Department of Emergency Medicine atMaine Medical Center
Dr Burton’s areas of research interest are procedural sedation and analgesia,emergency medical services, and management of cardiovascular emergencies He haspublished extensively in the emergency medicine literature on these and relatedtopics He has received awards and peer recognition throughout his academic careernoting a commitment to the specialty of emergency medicine
Dr Burton completed medical school at the University of North Carolina at ChapelHill in 1992 and residency training at the University of Pittsburgh Affiliated Residency
in Emergency Medicine in 1995
j a m e s m i n e r , m d , f a c e p, has been the Director of Performance Improvementand the Associate Research Director in the Department of Emergency Medicine atHennepin County Medical Center since 1999 and is an Associate Professor ofEmergency Medicine at the University of Minnesota Medical School
Dr Miner has performed extensive research in the areas of pain management andprocedural sedation in the Emergency Department and has published numerousmanuscripts on these topics He is an associate editor of Academic EmergencyMedicine
Dr Miner completed medical school at Mayo Medical School in 1996 and residencytraining at the Hennepin County Medical Center in Emergency Medicine in 1999
Trang 6CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo
Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
First published in print format
ISBN-13 978-0-521-87086-3
© John H Burton and James Miner 2008
Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of
publication Nevertheless, the authors, editors, and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors, and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.
2007
Information on this title: www.cambridge.org/9780521870863
This publication is in copyright Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.
ISBN-10 0-511-37133-0
ISBN-10 0-521-87086-0
Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.
Published in the United States of America by Cambridge University Press, New York www.cambridge.org
hardback
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Trang 7SECTION ONE OVERVIEW AND PRINCIPLES IN EMERGENCY
ANALGESIA AND PROCEDURAL SEDATION 1
1 Emergency Analgesia Principles
2 Emergency Procedural Sedation Principles
3 Analgesic and Procedural Sedation Principles Unique
to the Pediatric Emergency Department
4 Pain and Analgesia in the Infant
5 Provider Bias and Patient Selection for Emergency
Department Procedural Sedation and Analgesia
6 Federal and Hospital Regulatory Oversight in Emergency
Department Procedural Sedation and Analgesia
7 Nursing Considerations in Emergency Department
Procedural Sedation and Analgesia
SECTION TWO ANALGESIA FOR THE EMERGENCY PATIENT 43
8 Pharmacology of Commonly Utilized Analgesic Agents
9 Patient Assessment: Pain Scales and Observation in
Clinical Practice
10 Pathways and Protocols for the Triage Patient with Acute Pain
v
Trang 811 Patients with Acute Pain: Patient Expectations and Desired Outcomes
David E Fosnocht, Robert L Stephen, and Eric R Swanson 75
12 Analgesia for the Adult and Pediatric Multitrauma Patient
16 Analgesia for the Emergency Chest Pain Patient
17 Analgesia for the Emergency Back Pain Patient
18 Analgesia for the Acute Abdomen Patient
19 Analgesia for the Renal Colic Patient
20 Analgesia for the Biliary Colic Patient
21 Analgesia for the Chronic Pain Patient
23 Patient Assessment and Preprocedure Considerations
24 Monitoring for Procedural Sedation
Trang 925 Pharmacology of Commonly Utilized Sedative Agents
28 Procedural Sedation for Brief Pediatric Procedures:
Foreign Body Removal, Lumbar Puncture,
Bone Marrow Aspiration, Central Venous Catheter
Placement
29 Procedural Sedation for Adult and Pediatric Orthopedic
Fracture and Joint Reduction
30 Procedural Sedation for Electrical Cardioversion
31 Procedural Sedation for Brief Surgical Procedures:
Abscess Incision and Debridement, Tube Thoracostomy,
Nasogastric Tube Placement
SECTION FOUR TOPICAL, LOCAL, AND REGIONAL ANESTHESIA
APPROACH TO THE EMERGENCY PATIENT 205
32 Selected Topical, Local, and Regional Anesthesia
Techniques
33 Topical Anesthesia Considerations for Pediatric Peripheral
Intravenous Catheter Placement
34 Regional Anesthesia for Adult and Pediatric Orthopedic
Fracture and Joint Reduction
35 Regional Anesthesia for Dental Pain
36 Local Anesthesia for Laceration Repair
Trang 10SECTION FIVE SPECIAL CONSIDERATIONS FOR EMERGENCYPROCEDURAL SEDATION AND ANALGESIA 255
37 Sedation and Analgesia for the Prehospital Emergency Medical Services Patient
38 Induction Agents for Rapid Sequence Intubation of the Emergency Department Patient
39 Sedation and Analgesia for the Critical Care Patient
Trang 12Department of Emergency Medicine
Albany Medical College
43 New Scotland Avenue, MC 139
Albany, NY 12208-3479
Email: freemacj@mail.amc.edu
David French
Department of Emergency Medicine
Albany Medical College
43 New Scotland Avenue, MC 139
Maine Medical Center
Department of Emergency Medicine
22 Bramhall Street
Portland, ME 04102-3175
Email: gerrmc@mmc.org
Michael Gibbs
Department of Emergency Medicine
Maine Medical Center
Portland, ME 04102
Email: gibbsm@mmc.org
Steven M Green
Loma Linda University Medical Center
Department of Emergency Medicine A-108
11234 Anderson Street
Loma Linda, CA 92354
Email: stevegreen@tarascon.com
Donald JeanmonodDepartment of Emergency MedicineAlbany Medical Center
43 New Scotland AvenueAlbany, NY 12208Email: jeanmod@mail.amc.eduDawn B Kendrick
Division of Emergency MedicineDepartment of PediatricsUniversity of Alabama at BirminghamMTC 205
1600 7th Avenue SouthBirmingham, AL 35233-1711Email: dkendrick@peds.uab.eduBaruch Krauss
Children’s Hospital BostonDivision of Emergency Medicine
300 Longwood AvenueBoston, MA 02115Email: baruch.krauss@mac.comNathan Mick
Department of Emergency Medicine
47 Bramhall StreetMaine Medical CenterPortland, ME 04102Email: mickn@mmc.orgJames Miner
Department of Emergency MedicineHennepin Medical Center
701 Park Avenue SouthMinneapolis, MN 55415Email: Miner015@umn.eduMartha L Neighbor
1 Hawks Hill CourtLafayette, CA 94549-1900Email: mneighbor@sfghed.ucsf.eduDavid H Newman
Director of Clinical ResearchAssistant Professor of Clinical MedicineDepartment of Emergency Medicine
St Luke’s/Roosevelt Hospital Center
1111 Amsterdam AvenueNew York, NY 10025Email: dnewman@chpnet.org
Trang 13Andrew D Perron
Department of Emergency Medicine
Maine Medical Center
Portland, ME 04102
Richard Riker
Chest Medicine Associates
335 Brighton Avenue, Suite 200
Portland, ME 04102-2354
Email: Rikerr@mmc.org
Mark G Roback
Professor, Department of Pediatrics
University of Minnesota Medical School
Associate Director, Division of Pediatric
Emergency Medicine
University of Minnesota Children’s Hospital/Fairview
76 Variety Club Research Center
MMC 814, 420 Delaware Street SE
Minneapolis, MN 55455
Email: mgroback@umn.edu
Sharon Roy
Department of Emergency Medicine
Hennepin County Medical Center
701 Park Avenue South
30 North 1900 East Rm AC218
Salt Lake City, UT 84132
Tania D Strout
Maine Medical Center
Department of Emergency Medicine
Oregon Health Sciences University
3181 SW Sam Jackson Park RoadCDW-EM
Portland, OR 97201Email: sue@ohsu.edu
Eric R SwansonDivision of Emergency MedicineUniversity of Utah
30 North 1900 East Rm AC218Salt Lake City, UT 84132
Tim SweeneyDepartment of Emergency MedicineMaine Medical Center
Portland, ME 04102Email: sweent@mmc.orgPaula Tanabe
Department of Emergency Medicine and theInstitute for Healthcare Studies
Northwestern University
259 E Erie, Suite 100Chicago IL 60611Email: Ptanabe2@nmff.org
Knox H ToddProfessor of Emergency MedicineDirector, Pain and Emergency Medicine InstituteDepartment of Emergency Medicine
Beth Israel Medical CenterAlbert Einstein College of MedicineFirst Avenue at 16th Street
New York, NY 10003Email: ktodd@chpnet.orgMichelle P TomassiDepartment of Emergency MedicineAlbany Medical Center
43 New Scotland Avenue, A-139Albany, NY 12208-3478
Email: tomassm@mail.amc.edu
Trang 14Arleigh Trainor
Department of Emergency Medicine
Hennepin County Medical Center
Minneapolis, MN 55415
Wayne Triner
Department of Emergency Medicine
Albany Medical College
43 New Scotland Avenue, MC 139
Albany, NY 12208
Michael A Turturro
Clinical Professor of Emergency Medicine
University of Pittsburgh School of Medicine
Vice Chair and Director of Academic Affairs
Department of Emergency Medicine
The Mercy Hospital of Pittsburgh
1400 Locust StreetPittsburgh, PA 15219Email: turturro@pitt.eduAllan B WolfsonProfessor of Emergency Medicine
230 McKee Place, Suite 500Pittsburgh, PA 15213Email: wolfsonab@upmc.eduWilliam T ZempskyAssociate Director, Pain Relief ProgramConnecticut Children’s Medical Center
282 Washington StreetHartford, CT 06106Email: wzempsk@ccmckids.org
Trang 15but these signs are often absent As a consequence,
patient pain assessment remains an indirect estimation
by the treating physician It is, therefore, important to
use a consistent vocabulary in describing an assessment
of a patient’s pain This process will allow patient
findings to be communicated accurately and precisely
while a systematic treatment practice is implemented
Because pain is assessed almost completely through
patient report, patients who have difficulty
communi-cating are at risk of oligoanalgesia due to
under-appreciation of their pain Groups at risk include infants
and children, patients whose cultural background differs
significantly from the treating physician’s, and patients
who are developmentally delayed, cognitively impaired,
under severe emotional stress, or mentally ill
Unfamiliar or unrecognized attempts by the patient to
express pain may be misinterpreted by the physician,
leading to a poor interaction and an unclear assessment
of the patient’s pain (Table1-2) The accurate assessment
of pain in the face of cultural differences is a difficult, yetimportant challenge to overcome in order to treat painadequately
It should also be noted that many physicians haveencountered patients who have altered a prescription,have lost pain medications, seem to have pain out ofproportion to their illness or injury, or who ignore follow-
up clinic appointments and return to the ED repeatedly.These experiences can make it easy to view a patient’sreport of pain with skepticism Such observations andexperiences, like the physician’s assessment of patientpain, are significantly dependent on verbal and nonverbalsubjective communication between the physician andpatient This reality creates a substantial potential forinaccurate interpretations of patient motives in clinicalconditions where the patient pain experience is largelysubjective (e.g., back pain) with minimal opportunityfor objective clinical assessment with modalities such asradiographic imaging or laboratory testing
Table 1-1 Opioid receptors, activities, and subsequent endorphin responses to acute pain
Mu2 Respiratory depression, CV, and GI effects Beta-endorphin
Kappa Spinal analgesia, sedation, feedback inhibition Dynorphin
Gamma Psychomimetic effects, dysphioria
Table 1-2 Pathway/barriers to effective pain assessment and treatment
Complaint/assessment Patient communication
Physician bias Patient and physician concerns about the consequences
of treatment
Physician knowledge of treatment modalities Adverse events
Plan for ongoing
treatment
Physician knowledge of treatment modalities Patient compliance
Adverse effects of medications
2 Overview and Principles in Emergency Analgesia and Procedural Sedation
Trang 16PAIN CONSIDERATIONS
Acute pain follows injury and usually resolves as the
injury heals Acute pain may be, but is not always,
asso-ciated with objective physical signs of autonomic nervous
system activity such as tachycardia, hypertension,
dia-phoresis, mydriasis, and pallor When the cause of acute
pain is uncertain, establishing a diagnosis is the priority of
the emergency physician Symptomatic treatment of pain
should be initiated while the diagnostic evaluation is
proceeding In general, it is inappropriate to delay
anal-gesic use until a diagnosis has been made It is unlikely,
and unproven in medical literature, that treatment with
0.1 mg/kg of morphine, or another analgesic equivalent,
will mask signs or symptoms of progressive disease such
that the effective treatment of pain will confound the
diagnostic approach
Chronic pain is pain that has persisted after the usual
time of tissue healing has passed This is clearly a vague
definition with a great deal of ambiguity between acute and
chronic pain states Chronic pain is uncommonly ated with signs of sympathetic nervous system activity.The treatment of acute and chronic pain is different,and confusion between the two leads to poor manage-ment of patients Acute pain should be approached withthe intention of providing relief to a limited degree,individualized to each patient, with a plan to tapermedications as symptoms improve Chronic painassumes a baseline level of pain that is best treated with aconsistent approach to minimize baseline discomfortand minimize the adverse effects of both pain and paintreatment on the patient’s lifestyle
associ-ED personnel commonly identify patients who arethought to seek pain medications, usually opioids, forillegitimate purposes Drug addiction and prescriptionabuse occur throughout medicine specialties, and thetrue prevalence of addiction and drug-seeking behaviors
in the ED population is unknown
When patients are undergoing treatment with opioidmedications, the physician should be aware of the
Opioids Sedation/anesthesia
Peripheral nerve blocks as appropriate
Acetaminophen
Pain assessment
Figure 1-1 A generalized approach to the treatment of acute pain.