Transcript Acute pain

Taravat Fakheri
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 The
most common symptom to (ED)
 Assessment of severity of pain is subjective,
 All rely on patients’ perception
 Pain can be divided into two major
categories, acute and chronic.
Serves a physiologic function; a warning to
the patient that something is wrong,
 Transition point from acute to chronic
variably defined, ranging from as little as 4
to 6 weeks up to 6 months of pain.

 No
useful function to the pt.
 1-2ary to diseases as cancer, sickle cell
disease, and AIDS;
 2-Known pain syndromes as tic douloureux &
migraine headache;
 3-Without an identifiable cause;
 4-Those complain of chronic pain to obtain
drugs or for other personal gains.
 1-Cancer
patients with new pain or with
acute worsening of their previous pain should
be evaluated for a new complication and
their pain aggressively managed with
opiates.
 2-Patients
with known pain syndromes and
without objective cause for their pain
require an aggressive team approach.
 ex; patients with sickle cell disease and
frequent pain.
 3-those
who test the patience and
professionalism of emergency physicians and
nurses.
 The majority of these patients are seeking
narcotics.
 4-Malingering
Dx by exclusion,
 One approach ; use butorphanol (Stadol),
good analgesic activity but little euphoria.
 (NSAIDs) offered, but these patients will
often refuse them or state that they cannot
take them..
 Pain
is a combination of physical, chemical,
and psychological factors.
 Quantify the patient’s perception of the
degree of pain.
 Verbal report is the only way to reliably
obtain a patient’s evaluation of the pain.
 As
part of the triage process, and should be
located on the record where the vitals are
recorded.
 Record severity of pain during the initial
assessment process, and early and effective
management of pain should be ensured.
 After
treatment, the assessment should be
repeated as needed.
 Studies have documented inadequate use of
analgesic agents in the ED esp in the
pediatric population.
 Many patients do not receive any pain
medications while in the ED, even though
their primary presenting complaint was pain
 Inadequate
use of analgesics in the ED.
 Use of wrong agent; inappropriate dosage
and dosing intervals or route of
administration;
 improper use of adjunct agents;
 Concern for medically induced addiction to
narcotics.
 Failure
to give analgesics is an issue that
must be addressed by education of nursing
staff and physicians.
 Adequate
pain relief for all patients.
 Patient satisfaction may be directly related
to adequate pain control.
 Early
control of acute pain reduces the
incidence of chronic pain syndromes, and
may improve the patient’s outcome.
 Finally, health-care providers have taken an
oath to reduce or prevent pain and suffering.
 Requires
physician reeducation,
 Major changes in practice habits
 Parenteral
opioids.
IV line
 Dosage titrated
 Amount vary widely from patient to patient

 Efective
level varies as eight times greater
from one patient to another.
 IM should be avoided, painful and the
onset of action is variable.
 If an IV cannot be obtained ,SC an excellent
alternative.
 Newer agents ; sublingual or nasal route.
 Available
in sucker form, which has great
applicability in the pediatric population.
 Sufentanil and butorphanol, both potent
opioids, effective via the nasal mucosa.
 Once the route and dosage are determined,
the analgesic should be given at frequent
enough intervals to prevent the return of
pain
little role for adjunct agents in acute pain
in the ED.
 Exception; persistent nausea and vomiting
following the use of opioids, or
 pain + nausea and vomiting.

 Using
an adjunct to reduce the opioid dose
simply is not valid and exposes the patient to
another set of side effects. This practice
should be abandoned.
 The risk of addiction to the opioids with
medical use must be a concern for
physicians, especially when treating with
chronic pain
 less in acute pain.
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 Many
of these patients are women of
childbearing age or pregnant
 Providers evaluating such patients should be
familiar with the common causes of
abdominal pain in pregnant women
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 Up
to 80% of women experience nausea and
vomiting during pregnancy
 Symptoms and signs that may indicate
another cause for nausea and vomiting:


Symptoms past 20 weeks
Associated with abdominal pain, fever, or
diarrhea
 In
these instances, a more thorough
evaluation is indicated
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 Warning
signs that the cause may be
nonpregnancy related:


Pain localized, abrupt, constant, or severe
Pain associated with nausea and vomiting,
vaginal bleeding, or fever
 If
any of these are present, further
investigation is warranted and consultation
with an obstetric specialist is recommended
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 All
women of childbearing age who
present to the ED should have a
urine pregnancy test
 If
pregnant, the location and gestational age
of the pregnancy should be determined with
ultrasound
 Abortion & EP are the most common causes
of pain in early pregnancy

Both often also present with vaginal bleeding
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 In
general, the cause and incidence of nonobstetric abdominal pain in pregnancy varies
little by gestational age of the fetus
 The most common causes of acute abdominal
pain in pregnancy are (with incidences):





Appendicitis (1/1500 pregnancies)
Cholecystitis (1/3000)
Nephrolithiasis (1/3000)
Pancreatitis (1/3000)
Small bowel obstruction (1/3000)
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 Hx,PE
, pregnancy test, and ultrasound,
certain laboratory tests may be helpful



Complete blood count
Liver and pancreatic enzymes
Urinalysis
 If
diagnosis is still uncertain, prompt imaging
may be necessary
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 Imaging
in pregnancy should begin with
ultrasound or MRI


Neither has ionizing radiation
Neither has been linked to fetal harm
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 If
diagnostic tests with ionizing radiation
(e.g., computed tomography) are clinically
necessary, they should not be withheld, even
with concerns about fetal harm




Risk of harm to fetus is low, especially at lower radiation
doses
The radiation delivered in a CT scan of the abdomen and
pelvis is less than the dose known to cause fetal harm
As a rule, the smallest amount of ionizing radiation
should be used
CT scan in this setting should only be obtained after
obstetrical consultation
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Laparoscopy has become increasingly
popular in the treatment and evaluation
of acute abdomen.
 pregnancy not a contraindication for
laparoscopy ,
 Minimize manipulation of the uterus.

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

(A)
Pregnancy
Related Pain:
Early pregnancy
o Abortion:
Inevitable,
incomplete or
septic abortions
o Vesicular mole:
when expulsion
starts.
o Ectopic
pregnancy: pain
precedes
bleeding.

Later pregnancy
o Braxton-Hicks
Contraction
o Round Ligament Pain
o Pressure symptoms
o Cholestasis of
pregnancy
o Placental abruption
o Placenta percreta
o Acute Fatty Liver
o Pre-eclampsia ,
HELLP
o Spontaneous rupture
of the liver
o Uterine rupture
o Chorioamnionitis
o Acute
Polyhydramnios
o Labor ( Term ,
Preterm )
•
)
Irregular,
 Not progressively increasing
 Not associated with bulging of forebag of water or
dilatation of the cervix.
 Respond to anlgesics
 Cause women confusion as to whether or not they
were going into actual labor.
 They are thought to be part of the process of
effacement, the thinning and dilation of the cervix

Red Degeneration Of A Uterine Myoma
(syndrome of painful myoma)
 The
most common complication is the
syndrome of ‘painful myoma’; this is due to red
or carneous degeneration and occurs in 5–8%
of myomas during pregnancy
 This complication is associated with localized
pain of rapid onset, nausea, vomiting and
fever, tenderness, and an elevated white
blood cell count
 It usually occurs during the second trimester
of pregnancy
with advancing gestational age
as the uterine size increases.
The round ligaments, found on the
right and left sides of the uterus,
attach to the pubic bone and help
support the placement of the
uterus in the abdominal cavity.
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