EMERGENCY SEDATION AND PAIN MANAGEMENT - PART 4 pps

12 Analgesia for the Adult and Pediatric MultitraumaPatient Wayne Triner SCOPE OF THE PROBLEM CLINICAL ASSESSMENT OF PAIN AND MANAGEMENT OF THE MULTITRAUMA PATIENT PAIN/SEDATION CONSIDER

12 Trout A, Magnusson AR, Hedges JR Patient satisfaction

investigations and the emergency department: What does

the literature say? [In process citation] Acad Emerg Med

2000;7(6):695–709

13 Yarnold PR, et al Predicting patient satisfaction: A study

of two emergency departments J Behav Med 1998;21

(6):545–563

14 Larsen MJ, Fosnocht DE, Swanson ER Pain managementafter discharge from the emergency department AnnEmerg Med 2004;44(4):S88

15 Todd KH Pain and pain-related functional interferenceamong discharged emergency department patients AnnEmerg Med 2004;44(4):s86

12 Analgesia for the Adult and Pediatric Multitrauma

Patient

Wayne Triner

SCOPE OF THE PROBLEM

CLINICAL ASSESSMENT OF PAIN AND MANAGEMENT OF THE MULTITRAUMA

PATIENT

PAIN/SEDATION CONSIDERATIONS

PAIN AND SEDATION MANAGEMENT

Nonpharmacological Approaches to AnalgesiaStrategies in the Provision of Analgesic and Sedative AgentsRegional and Local Anesthesia

SUMMARY

BIBLIOGRAPHY

SCOPE OF THE PROBLEM

Multiple trauma is defined as injury to two or more

organ systems Without exception, pain is a major

consideration in the management of the patient with

multiple injuries Yet, the often-competing physiological

and operational demands associated with these patients

increase the complexity as well as the risk of meeting

their analgesic needs

Features such as extremes of age, dementia,

neuro-trauma, neuromuscular blocking agents, and intoxicants

impair a patient’s ability to express pain and limit

caregiver’s clinical assessment of pain Critical

care-based studies have demonstrated that a high proportion

of intubated patients have recollection of discomfort

and pain during the course of their illness Furthermore,

clinicians appear to attach a lower magnitude of pain to

patient’s conditions than do the patients themselves

Not surprisingly then, physician prescribing behavior

includes a tendency toward ineffective analgesia,

oli-goanalgesia, in traumatic conditions

For the year 2004, there were almost 1.4 million

hospital admissions for traumatic conditions (excluding

isolated hip fractures) Of these, 176,000 involved

chil-dren under the age 15 Given this magnitude and the

humanitarian goals of medical practice, attention toanalgesia in the multiply injured patient carries signifi-cant importance

The consequences of inappropriate analgesia in tiply injured patients are difficult to measure The psy-chological outcome of trauma patients hospitalized inintensive care units (ICUs) includes nightmares, pho-bias, recollection of pain and anxiety, and other ele-ments of posttraumatic stress disorder There are fewstudies, however, that have demonstrated that correct,over- or underutilization of analgesic or sedative agentsinfluence these psychological outcomes Studies thathave evaluated trauma patient outcomes in relation totheir physiological outcomes have not shown survival ormorbidity differences These investigations have showndifferences in intermediate outcomes such as interleukinlevels

mul-It can be concluded that underutilization of analgesia

to acutely injured patients is inhumane and renderspatient care difficult owing to patient resistance anddistress Poorly managed analgesia and sedation mayalso be associated specific markers of worse patientoutcomes including prolonged hospitalizations, hemo-dynamic instability, ventilator-associated pneumonia,and delirium

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CLINICAL ASSESSMENT OF PAIN AND

MANAGEMENT OF THE MULTITRAUMA PATIENT

Patient self-reporting is the most accurate means of

assessing pain (Figure 12-1) There are several

instru-ments that systematically define pain magnitude in thecommunicative patient The visual analog scale, verbaldescriptive scale, face scale, Face Legs Activity Cry Con-solability (FLACC), and modified FLACC scales have allbeen validated and are commonly available

Treat and stabilize

critical injuries

Consider regional anesthesia

Consider sedation/analgesia (depending on hemodynamic status – Figure 12.2)

Regional and/or systemic anesthesia/sedation/analgesia

Treat and

stabilize

critical injuries

Figure 12-1 Trauma patient initial evaluation and sedation/analgesia algorithm.

Patients suffering multiple injuries are often incapable

of focused communication This may be from

neuro-trauma, facial injuries, intoxicants, distraction, anxiety,

hypoxia, therapeutically induced sedation, and paralysis

In these situations, the clinician’s appreciation of pain

and its management can be easily overlooked

Alteration of vital signs is a poor indicator of pain

Compensation of hypovolemia, hyperthermia,

sympa-thomimetic, or anticholinergic intoxicants all may result

in tachycardia or hypertension Conversely, vagal

stimu-lation, use of calcium channel, and beta receptor blocking

agents, as well as age-related cardiac conduction

limita-tions, may limit the capacity for increases in heart rate and

blood pressure in traumatized patients with severe pain

Patients with traumatic injuries should be considered

to be in pain unless they can explicitly state otherwise

Patients with painful injuries that include alterations of

their mental status or patients who are

pharmacologi-cally paralyzed should receive appropriate analgesia

Likewise, anticipation of pain during procedures (e.g.,

wound repair, tube thoracostomy, fracture reduction,

line insertion) should warrant the anticipatory

admin-istration of systemic analgesia or local anesthesia despite

the lack of response from the patient

In the patient with altered mental status, there may be

several indicators of pain, particularly agitation

Agita-tion is a common response to pain and is in part related

to increased catecholamine stimulation Agitation also

increases metabolic demands, increases the likelihood of

the patient harming themselves or others, and renders

the provision of care more difficult

Assessment of the bispectral index can be an adjunct

to clinical examination in intubated patients under the

effect of neuromuscular blocking agents or sedative

procedures This modality is a mathematic index derivedfrom several electroencephalographic features

The bispectral index has been validated in ing depth of sedation and anesthesia in both the oper-ating room and ICU Its use has also been shown toreduce sedative agent dosing and time to waking fol-lowing general anesthesia The range of the index spans0–100 Zero is electroencephalographic silence and 100

determin-is full wakefulness Levels of 45–60 are typical of generalanesthesia whereas levels of 75–80 have been associatedwith sedative depths appropriate for procedures andcontinuous sedation of injured patients

PAIN/SEDATION CONSIDERATIONSCommon to many aspects of medical practice, one ismore likely to reach a successful outcome, if the goalsare first defined and they are realistic Such is the case inproviding analgesia in the face of complexities of themultiply injured patient To best define these goals, it isuseful to begin with the basic tenets of resuscitation:airway, breathing, circulation, and disability

Selection of agents and techniques to provide comfortcan often be done in such a manner that physiologicalrisk is minimized or that physiological goals can bereached as a result of analgesic intervention (Table 12-1)

It is often possible to choose combinations of techniquesand agents that enhance therapeutic efforts or minimizethe risk of physiologic deterioration

One caveat of administration of pharmacologic agentsfor analgesia in patients experiencing multiple trauma isthat all medications should be administered parenterally,preferably via an intravenous route This is because GImotility and absorptive capacity as well as sphlancnic

Table 12-1 Sedation and analgesia considerations for the trauma patient

neuroleptic, both)

perfusion may not be predictable This may also be true

of skeletal muscle and subcutaneous perfusion Orally

administered analgesic therapy may result in erratic or

delayed absorption in these patients Additionally, the

speed of onset and ability to titrate to specific analgesic

endpoints are enhanced by intravenous administration

Patients with multiple injuries can have complex

altera-tions in homeostatic mechanisms Hemodynamic and

respiratory consequences of their injuries are of primary

importance in the emergency department setting Once

the initial resuscitation is complete, mediators of

in-flammation, adrenal function, coagulation, and

gastro-intestinal performance are additional considerations

Since all analgesic and sedative agents impart their own

alterations in physiology, it is important to anticipate the

consequences of pharmacological intervention in

indi-vidual patients All but a few pharmacological agents

result in respiratory suppression and blunting of airway

reflexes Once a patient is intubated and mechanically

ventilated, respiratory and airway suppression becomes

less of a consideration, but the provision of ongoing

ventilator sedation and analgesia begin to merge Though

intubated, the provider must always consider the

ade-quacy of ventilation and the ultimate goal of extubation

PAIN AND SEDATION MANAGEMENT

Nonpharmacological Approaches to Analgesia

Nonpharmacological means of controlling pain should

be employed whenever possible The advantage to this

approach is that the patient may feel more in control

and there may be lesser requirements for drugs and their

adverse effects Simple measures such as ice, splinting

and repositioning may have significant impact

Whenever possible, spinal clearance should take place

early in the trauma patient assessment There is evidence

that spinal immobilization enhances pain Finally,

allowing family at the bedside, when feasible, and talking

to the patient in a sensitive and reassuring manner may

relieve anxiety and thus mitigate the pain experience

Strategies in the Provision of Analgesic and

Sedative Agents

Many of the agents used to provide analgesia and

sedation have the effect of reducing catecholamine

output and consequently vasomotor tone through

reduct ion of pregang lionic a drenergic tone (Figu re 12-2,Table 12-2) Thu s, if there ar e elem ents of card iac pumpfailure (tension pneumothorax, cardiac tamponade,congenital or acquired heart disease) or intravascularvolume depletion (blood loss, transudative or exudativefluid losses), hypoperfusion may result

Propofol and the ultra–short-acting barbiturates arethe agents most strongly associated with decreases inblood pressure Fentanyl is the opiate that is least likely

to potentate hypotension, yet with controlled tration over 3–4 min, all opiates may be considered safe.Etomidate is the least likely of sedative agents toadversely impact hemodynamic performance

adminis-The use of ketamine increases sympathetic tone with aresulting increase in blood pressure and heart rate Thiscan lead to increased metabolic demands, worsening ofaortic injuries and clot dislodgement from arterialinjuries Additionally, ketamine may be associated withincreases of intracranial and intraocular pressures,though this effect has been contested

Nitrous oxide has been used in many facilities andprehospital agencies for control of mild to moderatepain Nitrous oxide is commonly self-administeredthrough a commercially available blender, which pro-vides a 50% mixture with oxygen through a demandvalve (Nitronox) Its use requires an alert and coop-erative patient One of the physical properties of nitrousoxide is that it is far more tissue soluble than nitrogen.Therefore, closed gas compartments such as pneu-mothoracies and bowel obstructions can expand as aresult of nitrous oxide use

Dexmedetomidine (Precedex) is a unique agent that

is classified as an a2 adrenergic agonist Its principalmechanism of action is to reduce CNS presynapticnorepinephrine release, thereby resulting in sedation.Hypotension and heart block have been associatedwith the use of dexmedetomidine Dexmedetomidinesedation is unique in that patients experiencing sedationwith this drug maintain some degree of wakefulness(along with the ability to follow commands) whenstimulated Simultaneously, respiratory depression isminimal allowing patients to sustain respiratory minutevolume and ventilator tolerability There appears to

be limited impact on intracranial pressure associatedwith this agent It is not approved for sedation longerthan 24 hr

The use of dexmedetomidine is reported to reduce the

amount of opiates employed for analgesia and sedation

in the ICU setting Dexmedetomidine has also been

demonstrated to have utility in aiding ventilator

wean-ing It may also be useful for endotracheal intubation

when maintenance of spontaneous respirations is

desirable Currently there is limited experience with the

use of this drug in trauma patients, but there appears to

be potential benefits for selected patient populations.Patient-controlled analgesia (PCA) is a commonlyemployed technique for patients who are awake and canmanage medication through self-administration Thisstrategy is based on the premise that if a patient hascontrol over his or her own analgesia delivery, he or she

patients at risk of renal

failure or insult and

• Reduction of catecholamine output with potential of inducing hypoperfusion

Age > 13

• Nonpharmacological (positioning, reassurance)

• Any opiate infusion alone or in combination with Propofol or benzodiazepine infusion

• Regional anesthesia

Beware

• Oligoanalgesia

• Nonpharmacological (positioning, reassurance)

• Etomidate* bolus

• Fentanyl infusion alone or in combination with, benzodiazepine or ketamine* bolus if no brain injury

• Regional anesthesia Beware

• Oligoanalgesia

• Etomidate in patients

at risk of sepsis (bowel injuries, central venous access, anticipated prolonged ventilator course)

* often used to induce sedation as part of rapid sequence intubation.

Note that rapid boluses of opiates, benzodiazapines, and propofol enhance their potential to cause hypotension and respiratory suppression.

• Regional anesthesia

Volume resuscitation

Age > 13

Yes Requires sedation and analgesia

Figure 12-2 Algorithm for ongoing analgesia in multiply injured patient.

will experience less breakthrough pain and anxiety.

Generally, a provider obtains an adequate level of

an-algesia through carefully titrated opioid administration

Thereafter, a continuous basal infusion of an opioid is

established and the patient can deliver supplemental

boluses of the same opioid with the push of a button

attached to a delivery pump

The basal infusion rate, doses of patient administered

boluses, and hourly limits on boluses are programmed

into the delivery pump, which ensures these parameters

It is typical that a PCA be initiated following the initial

evaluation and management of most injuries PCA

management of pain has not been shown to be suitable

as a means of procedural analgesia or sedation

In the setting of multiple traumatic injuries,

particu-larly if the patient is being mechanically ventilated, the

provision of analgesia mingles with sedation There are

several agents, which serve to meet both of these needs

It is often desirable to titrate more than one agent to

minimize the deleterious effects of either drug alone

Since the experience of pain includes components of

anxiety, there is often a role for pure sedative agents in

enhancing patient comfort Therefore, the decision to

use both a benzodiazepine and an opiate continuous

infusion may reduce the potential for hypotension

Likewise, addition of an opiate infusion to a propofol

infusion to a patient with painful injuries would be

expected to reduce the dosage requirement for both,

thus reducing the occurrence of hypotension

Traumatic brain injury (TBI) is a common component

of multiple trauma Improving the outcome of TBI

patients relies principally upon avoidance or reduction of

secondary brain injury The overriding consideration in

the acute management of TBI is maintenance of

ventila-tion and cerebral perfusion pressure (CPP) Therefore,

hypotension and hypoventilation, based upon the

delete-rious effect on CPP, have been repeatedly associated with

adverse outcomes in patients with severe brain injury

Several of the agents used to provide analgesia or

sedation can have either positive or negative impact on

CPP depending upon how they are used Thus, careful

attention to maintenance of blood pressure is a key

element in providing sedation and analgesia to patients

with severe head injury

Propofol is the prototypical agent shown to maintain

cerebral blood flow and reduce ICP in the presence of

adequate intravascular volume Additionally, propofol is

an effective anticonvulsant and the least likely to result

in vomiting However, propofol in the hypovolemicpatient or the patient with limitations of cardiac outputwill potentate hypotension The reduction of CPPhowever, in the face of propofol-induced hypotension isnot proportional to the reduction of blood pressure due

to the reduction of systemic vascular resistance

Regional and Local AnesthesiaThe use of regional anesthesia is often overlooked in theinitial management of the multiple trauma patient.There are several techniques that are well within thetechnical reach of emergency physicians, trauma sur-geons, and orthopedists These can greatly enhance thecomfort of patients and avoid or reduce the adverseeffects of systemic analgesia Intercostal and femoralnerve blocks are examples of regional anesthesia that canreduce pain and opiate requirements in selectedpatients

Epidural blocks in the setting of chest trauma havebeen shown to reduce mortality, pneumonia, ventilatorinitiation, and days on a ventilator Epidural blocks arecontraindicated in cases where clinical examination ofthe abdomen is required due to anesthesia below thelevel of the block Generally, an epidural block is initi-ated and maintained by an anesthetist or anesthesiolo-gist Epidural catheters may be placed and left inposition for as long as several days When using regional

or local anesthesia for control of pain, long-acting agents(bupivucaine) are preferred

SUMMARYThe provision of analgesia and sedation are fundamentalskills in managing the multiply injured patient Thesepatients are complex from many standpoints and theadministration of pharmacological agents to managepain and affect sedation serve to increase their com-plexity

To safely and effectively provide sedation and gesia to the trauma patient, the provider must be able toidentify specific goals, anticipate the combined physio-logical effects of the injuries and analgesic modalitiesemployed There is no single practice or technique that

has proven safe or effective in all patients For any

in-dividual, several techniques for providing analgesia and

sedation will be equally safe and effective

BIBLIOGRAPHY

1 van de Leur JP, van der Schans CP, Loef BG, Deelman BG,

Geertzen JH, Zwaveling JH Discomfort and factual

recollection in intensive care unit patients Crit Care

2004;8:R467–R473

2 Guru V, Dubinsky I The patient vs caregiver perception

of acute pain in the emergency department J Emerg Med

2000;18:7–12

3 Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings

P Emergency department analgesia for fracture pain Ann

Emerg Med 2003;42:197–205

4 Moon MR, Luchette FA, Gibson SW, et al Prospective,

randomized comparison of epidural versus parenteral

opioid analgesia in thoracic trauma Ann Surg

1999;229:684–691

5 Petrack EM, Christopher NC, Kriwinsky J Pain

manage-ment in the emergency departmanage-ment: Patterns of analgesic

utilization Pediatrics 1997;99:711–714

6 Young J, Siffleet J, Nikoletti S, Shaw T Use of a

Behavioural Pain Scale to assess pain in ventilated,

unconscious and/or sedated patients Intensive Crit Care

Nurs 2006;22:32–9

7 Trope RM, Silver PC, Sagy M Concomitant assessment of

depth of sedation by changes in bispectral index and

changes in autonomic variables (heart rate and/or BP) in

pediatric critically ill patients receiving neuromuscularblockade Chest 2005;128:303–307

8 Miner JR, Biros MH, Seigel T, Ross K The utility of thebispectral index in procedural sedation with propofol inthe emergency department Acad Emerg Med 2005;12:190–196

9 Miner JR, Biros MH, Heegaard W, Plummer D Bispectralelectroencephalographic analysis of patients undergoingprocedural sedation in the emergency department AcadEmerg Med 2003;10:638–643

10 Kwan I, Bunn F Effects of prehospital spinal tion: A systematic review of randomized trials on healthysubjects Prehosp Disaster Med 2005;20:47–53

immobiliza-11 Bourgoin A, Albanese J, Wereszczynski N, et al Safety ofsedation with ketamine in severe head injury patients:Comparison with sufentanil Crit Care Med 2003;31:711–717

12 Avitsian R, Lin J, Lotto M, Ebrahim Z Dexmedetomidineand awake fiberoptic intubation for possible cervical spinemyelopathy: A clinical series J Neurosurg Anesthesiol2005;17:97–99

13 Triner W,Levine J, Lai SY, McErlean M Femoral nerveblock for femur fractures Ann Emerg Med 2005;45:679

14 Flagel BT, Luchette FA, Reed RL, et al Half-a-dozen ribs:The breakpoint for mortality Surgery 2005;138:717–723

15 Bulger EM, Edwards T, Klotz P, Jurkovich GJ Epiduralanalgesia improves outcome after multiple rib fractures.Surgery 2004;136:426–430

16 Green SM, Clark R, Hostetler MA, Cohen M, Carlson D,Rothrock SG Inadvertent ketamine overdose in children:Clinical manifestations and outcome Ann Emerg Med1999;34:492–497

13 Analgesia for the Emergency Department Isolated

Orthopedic Extremity Trauma Patient

SCOPE OF THE PROBLEM

Acute orthopedic injuries are among the most common

conditions seen in the emergency department (ED) In

2004, fractures, sprains, strains, and contusions

accounted for 14.3 million of the total 110.2 million ED

visits in the United States Acute orthopedic injuries

typically cause acute pain and consequent guarding of

the injured part by the patient in an effort to reduce the

pain Although this innate response prevents further

injury, appropriate initial management of pain will allow

more rapid mobilization and return to normal function

Conversely, uncontrolled pain may lead to adverse

physiologic consequences such as prolonged

immobili-zation increasing the risk of thromboembolic

compli-cations, limitation of range of motion, and muscular

atrophy

CLINICAL ASSESSMENT

The extent of acute orthopedic injury can often be

predicted by the mechanism of injury For example, a

fall on an outstretched hand may indicate a Colle’s,

scaphoid, or radial head fracture; a twisting injury to the

knee with an audible pop may indicate a rupture of the

anterior cruciate ligament

First and foremost in the examination of acute

orthopedic injuries is a primary survey to detect potential

life-threatening injuries Then, a general assessment of theinjured part by inspection, palpation, and range ofmotion should be performed to exclude immediate limbthreats (e.g., a fracture dislocation of the ankle withvascular compromise) and to assess for deformity, limi-tation of range of motion, and overlying soft tissueinjuries The skin examination should focus on thedetection of abrasions, puncture wounds, and lacerationsthat could require repair

A more thorough examination should be undertaken

to assess for additional injuries, regardless of severity.Though it is important to thoroughly evaluate areasobviously injured and areas in which the patient com-plains of discomfort, additional injuries could poten-tially be overlooked unless a more thoroughexamination is performed

Finally, neurovascular assessment should be taken to evaluate for associated nerve or limb-threateningvascular injuries and to recognize signs associated with apotential compartment syndrome, in which the mostcommon and earliest sign is pain (Table13-1)

under-Plain film radiographs should be ordered if on history

an examination there is concern for either a fracture or adislocation Well-validated clinical decision rules havebeen developed and implemented for the appropriate use

of plain film radiography in acute ankle and knee injuries.Since not all fractures are immediately radiographicallyapparent, if there is a strong clinical suspicion for a

87

fracture despite negative plain films, the injured part

should be splinted and the patient should be referred for

delayed plain films in 7–10 days, computed tomography,

or magnetic resonance imaging

PAIN CONSIDERATIONS

After local injury, an inflammatory cascade occurs in which

prostaglandins and kinins are released These substances in

turn lower the threshold for stimulation of C-type fibers of

the surrounding tissues These fibers terminate in the

dorsal horn of the spinal cord, at which several excitatory

neurotransmitters and substance P are released, stimulating

nociceptive neurons that consequently transmit painful

impulses to the central nervous system

Based on these mechanisms, analgesia in the patient

with an acute orthopedic injury can take several forms:

1 Reduction of inflammatory mediator release by

local measures (e.g., ice, splinting)

2 Inhibition of the local inflammatory cascade by

the use of systemic anti-inflammatory agents

3 Nerve blocks of the involved peripheral nerves by

local or regional anesthetic techniques using local

anesthetics

4 Intrathecal or epidural administration of local

anesthetics or opioids (beyond the scope of the

typical emergency physician’s practice)

5 Modulation of the response to the painful

stimulus within the central nervous system by

the use of systemic opioid analgesics

6 A combination of two or more of the above

approaches

PAIN MANAGEMENT

Appropriate analgesia in the acute phase of orthopedicinjuries is essential to proper patient management As ithas been demonstrated that effective preoperative an-algesia by a multimodal approach decreases postopera-tive analgesic requirements, effective analgesia provided

in the ED may be associated with decreased analgesicrequirements postdischarge Additionally, if there are nocontraindications, analgesia can and should be under-taken as soon as possible after patient arrival In the EDthis could entail the use of standing orders for analgesicsand nonanalgesic therapy at triage and/or protocols thatallow analgesics to be administered prior to radiography(Figure13-1)

One of the first and simplest steps in the management

of pain from an acuteorthopedic injury is immobilization of the injured part

in a position of function This intervention is thought toreduce pain by reducing release of inflammatory media-tors when the injured part is manipulated In the ED, thismay initially entail simple techniques such as resting aninjured extremity in the position of comfort on a pillow

In the case of joint dislocations and fractures, reductionand realignment followed by immobilization by the use ofsplinting will accomplish this goal (Table13-2)

Cryotherapy (the use of ice) is also one of the easiestalthough sometimes ignored techniques that may beused in the ED and in the first few days of therapy toreduce the pain associated with acute orthopedic inju-ries Ice causes local vasoconstriction, therefore lessedema and local inflammatory release occur, therebyreducing pain Compression and elevation also mayreduce local tissue edema, in turn reducing overall pain

In initiating cryotherapy, to reduce the risk of related injury (e.g., frostbite), ice should be applied at amaximum of 15 min intervals several times a day.Conversely, the use of thermal therapy (i.e., heat) hasbeen associated with minor reductions in pain associ-ated with acute and subacute myofascial strains, but it isnot first-line treatment for the pain of contusions,fractures, and dislocations

cold-In the pharmacotherapy of acute orthopedic injuries,based on the concept of reducing the release of localinflammatory mediators, analgesia can and should beinitiated with an nonsteroidal anti-inflammatory agents

Table 13-1 Clinical signs of compartment syndrome

Decreased perfusion (late finding)

Decreased capillary refill

Decreased pulses

to individualize analgesia to either a single dose of

an oral agent or titrated intravenous analgesia In

most cases, emergency physicians should have a

low threshold to institute titrated opioid analgesic

therapy for patients with acute orthopedic injuries

2 In the acute phase after injury, in an effort to keep

pain under control, opioid analgesics should be

prescribed at fixed intervals based on the

phar-macokinetics of the analgesics used rather than

‘‘prn’’ dosing

3 Combination opioid-nonopioid products may be

beneficial since a lower dose of each component

could be utilized to achieve adequate analgesia

and minimize the risk of side effects

4 In patients with acute orthopedic injuries who are

otherwise healthy and young with no significant

comorbidities, reasonably large starting doses of

opioid analgesics should be utilized, with

addi-tional boluses every 10–15 min until the pain is

adequately controlled (Figure13-1, Table13-3)

FOLLOW-UP/CONSULTATION

CONSIDERATIONS

Orthopedic consultation should be obtained for any

fracture that will require operative intervention, patients

requiring admission, or urgent follow-up An adequate

quantity of analgesics should be prescribed for the

interval between ED visit and anticipated follow-up, to

minimize the need for a repeat ED visit for analgesia.Explicit follow-up instructions regarding splint care,crutches, and weight bearing should be provided Signs

of potential compartment syndrome should beexplained to the patient and documented on the follow-

up form, with instructions to return as soon as possibleshould any of these signs develop

BIBLIOGRAPHY

1 McCaig LF, Nawar EW National Hospital AmbulatoryCare Survey: 2004 emergency department summary U.S.Department of Health and Human Services, 2006

2 Katz J Pre-emptive analgesia: Evidence, current status andfuture directions Eur J Anesthesiol 1995;10:8–13

3 Hubbard TJ, Denegar CR Does cryotherapy improveoutcomes in soft tissue injury J Athl Train 2004;39:278–279

4 French SD, Cameron M, Walker BF, et al A Cochranereview of superficial heat or cold for low back pain Spine2006;31:998–1006

5 Schwartz NA, Turturro MA, Istvan DJ, Larkin GL.Patients’ perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect onanalgesia Acad Emerg Med 2000;7:861–867

6 Koester MC, Spindler KP Pharmacologic agents infracture healing Clin Sports Med 2006;25(1):63–73

7 Paice JA, Noskin GA, Vanaqunas A, Shott S Efficacy andsafety of fixed dosing of opioid analgesics: A qualityimprovement study J Pain 1995;6:639–643

8 Center for Disease Control and Prevention, NationalCenter for Health Statistics, Adv Data 2006;372:1–29

Table 13-3 Initial opioid analgesic dosing for the

patient with acute musculoskeletal injury and no

14 Analgesia for Selected Emergency Eye and Ear Patients

FOLLOW-UP/CONSULTATION CONSIDERATIONS

SUMMARY

BIBLIOGRAPHY

SCOPE OF THE PROBLEM

Eye and ear problems are common complaints in the

emergency department (ED), with corneal abrasion and

acute otitis media (AOM) being the most common

di-agnoses AOM is the most common diagnosis made by

physicians in the United States in children under 15 years

old, with an estimated incidence in children between 17%

and 32% per year In one study as many as 80% of

children were diagnosed with AOM by age 3 with 40% of

those diagnosed with more than three episodes Although

AOM is predominantly a childhood illness, it does occur

in adults with a much lower incidence

Pain is the most common complaint associated with

the diagnosis of AOM in both adults and children

Recent literature describes the importance of aggressive

pain management in patients with AOM irrespective of

any decision to treat with antibiotics Otitis externa is

another common complaint associated with ear pain,

which has important diagnostic and treatment

differ-ences, including the management of pain

The eye is well protected Most of the eye lies within

the orbit, and its anterior surface has both anatomic and

functional protections The tear response washes away

anything that reaches the eye surface Eyelashes and

eyebrows shield the eyes, and eyelids can rapidly close to

protect the eye Even with all these protections the eye is

easily injured The most common and clinically cant eye injury in patients presenting to the ED is thecorneal abrasion

signifi-Although the corneal epithelium heals quickly ally within 24–48 hr), a corneal abrasion can be a de-bilitating injury It causes significant pain, and a cornealabrasion can affect vision depending on the nature andlocation on the corneal surface Patients often remainout of work during the corneal abrasion healing processsecondary to both visual disturbance and the side effectsfrom narcotic analgesia

(usu-CLINICAL ASSESSMENT

The initial approach in assessing a patient with a plaint of ear pain is taking a clinical history The patientmight report any of a multitude of symptoms, includingfever, chills, poor appetite, and pulling at the ears InAOM, there will be acute onset of pain, fever, and signs ofmiddle ear inflammation as indicated by either erythema

com-of the tympanic membrane (TM) or distinct otalgia, aswell as signs or symptoms of middle ear effusionincluding bulging of the TM, limited or absent TMmobility, air-fluid level behind the TM, and otorrhea Adefinitive diagnosis of AOM must meet three criteria:rapid onset, middle ear effusion, and middle ear in-flammation

91

Pain is also a predominant complaint in otitis externa

but, unlike AOM, the pain can be elicited by directly

manipulating either the tragus or the auricle On direct

visualization the external auditory canal will be

ery-thematous and edematous with an exudate within the

canal The severity of illness and the need for antibiotics

should be determined for each patient

Paramount to the diagnosis and treatment of both

AOM and otitis externa is the need for adequate pain

control It is also important to note whether the TM is

intact as this impacts analgesic options and selection

An interview of the eye pain patient will often reveal a

history of recent ocular trauma and subsequent acute

onset of pain suggestive of a corneal abrasion The

patient might also report photophobia, tearing, foreign

body sensation, blurry vision, headache, and pain with

extraocular muscle movement The patient might not

give a history of trauma as corneal abrasion can result

from minimal trauma such as eye rubbing

Corneal abrasion is diagnosed by direct visualization

of the corneal epithelium using a slit lamp and should be

aided by the use of cobalt-blue light and flourescein dye

Corneal abrasions that involve multiple layers and/or are

in the visual axis can lead to visual deficits, making it

important to document visual acuity Globe penetration

should also be considered, especially if the mechanism is

concerning, that is, high-speed grinding In this case

Seidel’s test can be used to aid in the diagnosis

PAIN CONSIDERATIONS

Both eye and ear complaints are common in the ED and

can elicit significant pain It is important to recognize

pain early and treat effectively, particularly as

exam-inations of the eye and ear can worsen a patient’s pain

and anxiety Children presenting with AOM often have

significant pain, anxiety, and distress, rendering a good

physical examination difficult to perform

For the treatment of pain associated with AOM, it is

beneficial to begin with oral medications such as

acet-aminophen or ibuprofen in an attempt to reduce a

child’s pain prior to exam In practice, these medications

are often given after the exam and sometimes only when

fever is present

There are many studies suggesting inadequate pain

control by emergency physicians with the pediatric

population suffering the most Treating children early,particularly if there is significant pain, will help with theexam by decreasing the child’s pain and anxiety over theexam of a painful ear Pain medications in the form ofdrops, for example, Auralgan, should be withheld until

an intact TM can be visualized as they can be damaging

to the middle ear

Similar to the ear, examination of the painful eyeoften elicits significant anxiety Patients may have sig-nificant discomfort even with the simple act of openingthe eyes Blurry vision, tearing, and photophobia mightalso be present in these patients, further challenging theclinician Easing patients’ fears and treating their eyepain early and adequately prior to exam will greatlyenhance patient comfort as well as one’s ability to per-form a good physical exam It should also be noted thatrapidly acting ophthalmic anesthetics do not adverselyaffect the examination of the eye

PAIN MANAGEMENT

OtologicThere are many factors to consider when treating earpain: source of the pain, seriousness of the infection, age

of the patient, whether the TM is intact Treatment ofear pain may, and in some circumstances should, bestarted even before the examination of the patient withoral pain medications Ear drops (Auralgan/lidocaine)are not appropriate at this stage as they require visual-ization of an intact TM prior to use

In several small studies, ibuprofen dosed at 10 mg/kg

in the pediatric population has been demonstrated assuperior to acetaminophen in the treatment of painassociated with AOM This difference, although small,should be considered if choosing a single medication Ifthe child is in significant pain, a combination of acet-aminophen (15 mg/kg) and ibuprofen should be con-sidered If the pain is severe and particularly difficult tocontrol, narcotics should be considered Codeine elixirhas been shown to effectively treat moderate to severepain associated with AOM in children

If the TM is visualized to be intact, anesthetic drops inthe form of either Auralgan (benzocaine/antipyrine),Americaine otic, or 4% lidocaine may be instilleddirectly into the ear canal These medications are veryfast acting and provide excellent pain control Anesthetic

drops are particularly helpful during the acute stage of

an AOM infection, as most studies indicate that pain

from AOM generally resolves after 48–72 hr

If otitis externa is diagnosed, nonsteroidal

anti-in-flammatory agents (NSAIDs) are the treatment of choice

for pain relief The treatment for otitis externa involves

cleaning the canal if possible and antibiotics as

indi-cated Cleaning the canal is an important step and

topical analgesics, such as Auralgan, Americaine otic,

or 4% lidocaine, can be an important adjunct to relieve

the pain associated with this intervention Prolonged use

of topical otic drops is generally contraindicated as otic

drops can cause irritation to the raw skin associated with

otitis externa (Table14-1)

Ophthalmic

Patients with corneal abrasions often describe significant

debilitating pain Although the pain is generally short

lived, lasting generally 48 hr, it is often significant

enough to limit their daily activities Patients with

cor-neal abrasions will require narcotic analgesia

The issues with analgesia for corneal abrasions address

two practical concerns: anesthetics for acute eye pain in

the ED and discharge analgesia Anesthetic drops provide

excellent anesthesia with rapid onset Prolonged use of

anesthetic drops may cause corneal damage, however

The two most common ophthalmic anesthetic drops in

use are tetracaine and proparacaine Both medications

have similar rapid onset and initial pain during

instilla-tion, though tetracaine has been shown to cause more

pain with instillation than proparacaine Proparacaine has

also been demonstrated to have a longer duration ofclinical effects

An attempt has been made to buffer both of thesemedications, similar to buffering lidocaine beforeinjection, to alleviate the pain associated with applica-tion to the eye This approach appears to result in ele-vated pain associated with instillation With nosignificant difference in price between the two agents,and with proparacaine associated with both less dis-comfort during instillation and longer duration ofaction, proparacaine would appear to be the moreappropriate choice for most corneal abrasion patients.Adequate analgesia for patients following discharge isimportant for corneal abrasion patients and can greatlyimprove patient comfort during their healing Themainstays of treatment for these patients are usually oralNSAIDs and narcotics

Historically, eye patching was used as a means todecrease the pain associated with corneal abrasion Eyepatching, however, has been demonstrated to confer nobenefit in the reduction of pain Patching has also beenassociated with an increased risk of infection followingcorneal abrasion Eye patching is no longer recom-mended as a routine intervention for corneal abrasionpatients

Another option that is emerging as an option foranalgesia in corneal abrasion patients is the use ofNSAID ophthalmic drops Ketorolac 0.5%, diclofenac0.1%, and indomethacin 0.1% drops have all been used

to treat the pain associated with corneal abrasion.Numerous studies, including a recent meta-analysis

Table 14-1 Selected analgesic options for patients with AOM and otitis externa

Acetaminophen, Ibuprofen Readily available, effective for mild to

moderate pain Studies suggest ibuprofen achieves better analgesia in AOM Topical agents – if TM is intact

Codeine, hydrocodone, oxycodone Gastrointestinal upset and constipation

are common