Picture the scene…
You are in the “Minors” area of the ED when the triage nurse approaches you and asks you to prescribe some pain killers for a patient with a sprained ankle. “He has already tried paracetamol and brufen at home – what else can I give him?…”
Learning Objective
To learn about the management of the patient in pain in the Emergency Department.
Task 1 – Read
Read this blog post from RCEM Learning1. Concentrate particularly on the introduction and pain assessment tools.
Task 3 – Discuss
This part of the teaching session should be lead by an experienced clinician. The cases provided are merely examples and if possible the learners should be encouraged to discuss patients they have seen in their clinical practice and how they approached them. Focus particularly on the analgesic options available in your Emergency Department.
Case 1 – A patient with mild pain
A 45 year old male patient presents to the ED complaining of a painful knee after playing football.
1, What pain relief would you recommend for mild pain?
Usually ‘simple’ analgesia like paracetamol and a non steroidal (NSAID) are a good place to start. Sometimes patients will not take pain killers before seeing you as they do not want to ‘mask the pain’. Of course, this isn’t true and it’s always worth reminding patients that you’ll be able to do a full assessment even if they have taken some tablets.
2, What are the contraindications to NSAIDs?
NSAIDs can be excellent pain killers, but should be used with caution in the elderly2.
The main side effects are:
- indigestion – including stomach aches, feeling sick and diarrhoea
- stomach ulcers – these can cause internal bleeding and anaemia; extra medicine to protect your stomach may be prescribed to help reduce this risk
- headaches
- drowsiness
- dizziness
- allergic reactions
- in rare cases, problems with your liver, kidneys or heart and circulation, such as heart failure, heart attacks and strokes
NSAIDs may worsen asthma in suscitible individuals.
3, Which NSAID is most appropriate for this patient and why?
In this patient’s case ibuprofen is probably the best NSAID to prescribe – it has the fewest side effects and is a reasonably effective analgesic.
Note that if inflammation is a major feature (such as in acute gout) ibuprofen is probably less effective than diclofenac or naproxen.
Case 2 – A patient with moderate pain
A 38 year old man presents with a 6 hour history of abdominal pain, which he describes as “moderate”. He hasn’t taken any painkillers.
1, Which would be better for this patient – oral or intravenous paracetamol?
There he been very little evidence3 to show that intravenous paracetamol is superior to oral in terms tof analgesic effect, however, you may want to keep this patient nil by mouth, or he may be actively vomiting, in which case you would choose the intravenous route.
2, If his pain isn’t controlled with paracetamol which analgesic would you try next?
If he is unable to take NSAIDs (and there may be a concern about these worsening his abdominal pain) it wouldn’t be unreasonable to move to opiod analgesia. In the ED we would probably titrate intravenous morphine, although oral dihydrocodeine could be an option.
3, Which is “better” – dihydrocodeine or codeine?
Codeine is converted to morphine in the liver by a cytomchrome p450 enzyme (CYP2D6), this its metabolism can be affected hugely by the expression of this enzyme (eiother positively or negatively), and the effect of other medications on its action. Approximately 10% of people are non metabolisers of codeine and will have no analgesic benefit at all.
Dihydrocodeine is twice as strong as codeine and doses of 30mg (up to four times a day) are as effective as 60mg, with fewer side effects.
Case 3 – A patient with severe pain
A 25 year old woman presents having come off her motocross bike. Her left leg is incredibly painful and the femur was deformed at scene. Th prehospital team have straightened this out and placed it in a splint.
1, What would be your first line analgesic for the patient?
If you’re ever not sure what you should prescribe think what you would want for a member of your family. This patient needs intravenous morphine, likely a dose of at least 0.1mg/kg.
2, What other options are there for pain relief in this patient?
Always consider other methods of pain relief apart from injectable drugs. Splintage can be very effective as a means of reducing pain. In this patient with a femoral fracture a femoral nerve block is a safe and very effective way of blocking the pain signals that are being produced at the site of injury.
Task 4 – Summary
Relieving pain is one of the key roles of a doctor. Do not delay getting the patient the pain relief they need.
Task 5 – Reflect
In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.
Was this a topic that you were confident you knew already? Which parts were new to you? Were there elements that you will use on your next clinical shift.
Dscuss this session with your colleagues – were there people who missed it who you can share the highlights with?
References and Further Reading
- 1Lloyd G. Pain Management in Adults. RCEM Learning. 2018; published online Jan 29. https://www.rcemlearning.co.uk/reference/pain-management-in-adults/ (accessed June 16, 2020).
- 2Non-steroidal anti-inflammatory drugs. Electronic BNF. https://bnf.nice.org.uk/treatment-summary/non-steroidal-anti-inflammatory-drugs.html (accessed June 16, 2020).
- 3Furyk J, Levas D, Close B, et al. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J 2017; : 179–84.