Transcript Pain Management in the ED

Pain Management
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Introduction for incoming
Trainees.
Includes UMHHC specific
information.
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June/July Orientation
Revised 5/2008
….is a Medical
Emergency !!
Revised 5/2008
It’s more than a good
idea……it’s the law.
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1992: US Department Health
and Human Services Report on
Acute Pain Management notes
pervasive under-treatment and
establishes guidelines
1997: Congress defined pain as
a medical emergency….
2001: Pain Standards developed
by JCAHO are in effect
Revised 5/2008
Physicians often fail to
identify pain...
And even when
recognized, pain is
often under-treated….
Revised 5/2008
Opioid Dosing
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Opioid analgesia is most
effective when titrated to
effect.
Effective doses are highly
variable between patients.
“Standard” doses may be
insufficient.
When used properly for
analgesia addiction occurs in
less than 1% of patients.
Revised 5/2008
Addiction, Physical
Dependence, Tolerance
Defined
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Addiction
Psychological dependence and
aberrant use of drug
characterized by compulsively
taking the drug despite harm
Physical dependence
Differs from addiction.
Dependence is a physical
response to continued use of
narcotics.
Tolerance
Decrease in susceptibility to the
effects of a drug due to its
continued administration
Revised 5/2008
Pain must be
assessed in every
patient at UMHS
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When performing History
& Physical Examination
Daily while evaluating
inpatients
During outpatient visits
Revised 5/2008
Factors to consider in pain
assessment may include,
but are not limited to:
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Location, intensity, quality, character
Duration, fluctuation, pattern
Associated symptoms and signs
Contribution of depressed or anxious
mood
Aggravating and alleviating factors
Impact on functional ability
Prior pain management interventions
and their effects
Current pain management methods
and their effects
Personal goals for pain relief and
functionality
Side effects of therapies
Revised 5/2008
Documentation of Pain:
Requirements
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Example for H&P’s: “He describes his back
pain as very sharp and burning as opposed
to the dull nature that it was prior to an
accident. He now rates it as a 9/10. He
states his average ranges from 6, most of
the time, to as great as 10.”
Example for an impatient note: “The
patient states that he had difficulty sleeping
last night because of pain in the sternal
area. He admits to having had this type of
pain frequently in the past. He describes
pain as “burning like fire” with variable
intensity. At the worst he reports pain as a
7/10 on a scale of 0-10. His pain is
currently 0/10….”
Revised 5/2008
Factors to consider in
choosing a pain scale
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Age of patient
Physical condition
Level of consciousness
Mental status
Ability to communicate
Revised 5/2008
Numeric Pain Rating
Scale
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0 1 2 3 4 5 6 7 8 9 10
Ask the patient to rate their pain intensity
on a scale of 0 (no pain) to 10 (the worst
pain imaginable).
Some patients are unable to do this with
only verbal instructions, but may be able to
look at a number scale and point to the
number that describes the intensity of pain.
Revised 5/2008
Wong-Baker FACES
Pain Rating Scale
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Can be used with young children (sometimes
as young as 3 years of age)
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Works well for many older children and adults
as well as for those who speak a different
language
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Explain that each face represents a person
who may have no pain, some pain, or as much
pain as imaginable. Point to the appropriate
face and say the appropriate description. e.g.
“This face hurts just a little bit”
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Ask the patient to choose the face that best
matches how she or he feels or how much
they hurt.
Revised 5/2008
Color Pain Rating
Scale
Ask the patient to point to
the area on the scale that
shows their level of pain
from white (no pain) to dark
red (worst possible pain).
Obtain a number
corresponding to the area
where the patient points.
Revised 5/2008
Meperidine (Demerol ®)
Restrictions on use:
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Only available at UMHS for Management
of infusion-related reactions (rigors) or
post-operative shivering.
At its May 2002 meeting, the Pharmacy
and Therapeutics Committee voted to
remove Meperidine from the Formulary
for pain control.
Meperidine should not be used to treat
pain in patients who have sickle cell
disease, a history of seizures, or chronic
pain
Revised 5/2008
Meperidine (Demerol ®)
metabolite:
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Meperidine should not be
used in high doses for
prolonged durations.
Its active metabolite,
normeperidine, accumulates
after repeated high doses.
May induce tremors,
myoclonus and generalized
seizures.
Revised 5/2008
Morphine:
Caution
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Morphine has an active metabolite excreted by the
kidney, morphine-6-glucuronide (M6G).
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M6G is 4 to 20 times more potent then morphine.
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As creatinine clearance decreases,
ratios of metabolites rise exponentially.
 Analgesic and respiratory depressant effects are
related to serum concentrations of both morphine
and M6G.
 As renal function declines, estimation of creatinine
clearance is important for morphine dosing.
Impaired renal function warrants use of an
alternative opioid analgesic if repeat dosing is
planned or expected.
Revised 5/2008
You have just written an order
for:
“2 mg Hydromorphone IV Push”
Do you know that:
Hydromorphone is NOT Morphine
Hydromorphone is also known as
Dilaudid
1 mg of Dilaudid is about as potent as
7.5 mg of Morphine
Did you really intend to give this patient the
equivalent of :
15 mg of Morphine IV push ?
If not rewrite the Hydromorphone order as
“0.2 mg Hydromorphone IV push”Revised 5/2008
Dilaudid
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(Hydromorphone)
Caution
YOU !
must be alert to the
possibility of overdose
when using Dilaudid
(hydromorphone) in
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opiate-naive patients
the elderly
pediatric patients
Revised 5/2008
Opioid Range Orders
FYI:
“Morphine 2-6 mg IV q 3-4 hours, prn”
This order is not permitted per JCAHO at UMHS
Correct Form:
“Morphine 2-4 mg IV q 3 hours prn for
pain”
Better Form:
“Morphine 2 mg IV q 3 hours prn for pain.
If pain score >5/10 may increase
Morphine dose to 4 mg IV q 3 hours.”
Revised 5/2008
Opiod use in the
Elderly:
Caution
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Always consider reducing the
average adult dose by 25-50%
Titrate up slowly
Reassess frequently while
adjusting opioid dosing to
prevent over or under dosage
Revised 5/2008
Realistic pain treatment
goals must consider
patient expectations
PA I N
Revised 5/2008
Next Steps
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Complete the Pain Management Test.
There are 8 questions.
Use the resources available to you
such as the “Pain Pocket Card” which is
attached to this computer.
Please DO NOT remove this card. You
will receive your own card when you
exit this station.
Welcome to UMHS and Best Wishes!
Revised 5/2008