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Chapter 9: Emergency Pain Management

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To describe the various types and classifications of pain, and their underlying pathology.

-To rapidly and comprehensively assess a person's pain in the emergency care setting.

-To use a range of strategies to effectively manage a person's pain in the emergency care setting.

-To work appropriately in the context of the complex ethical issues involved in pain management.

What is pain?

Pain is a complex, multidimensional concept. It is subjective and universally accepted as an unpleasant experience, involving suffering. Pain is caused by a range of physiological problems and, less commonly, by psychological dysfunction. In this chapter, we will focus on pain caused by physiological problems.

The term nociception is used to describe the physiological processes which allow information about tissue damage to be communicated to the central nervous system (CNS), interpreted as 'pain'. There are four processes involved in nociception:

  1. Transduction involves the conversion of a painful stimulus (mechanical, thermal or chemical) into an action potential, which is transmitted along pathways of nerves, from the peripheral nervous system (PNS) to the CNS.
  1. Transmission involves the movement of the electrical 'pain' signal into the CNS. From the spinal cord, the pain signal is transmitted to the thalamus and the cortex in the brain.
  1. Perception involves the brain recognising the stimulus as 'painful', and responding to it. This is a complex process with many unknown steps.
  1. Modulation is the final step in nociception; it determines how the brain perceives the 'pain' signal, and acts to relieve the experience.

Pain can be classified in a number of different ways. It is useful to think of pain as either: (1) nociceptive, or (2) neuropathic.

Nociceptive Pain

Neuropathic Pain

Definition

Normal processing of the noxious stimulus that has damaged, or has the potential to damage, the body.

Abnormal processing of the noxious stimulus; processing problems may occur in the PNS or CNS.

Types

Somatic pain: From bone, joint, muscle, skin, connective tissue; described as 'aching' or 'throbbing'; usually localised.

Visceral pain: From the organs; may be well-localised or poorly localised.

Centrally-generated pain: Occurs through direct damage to the PNS or CNS, or due to dysregulation in the autonomic nervous system.

Peripherally-generated pain: This occurs when pain is felt along a single nerve (a mononeuropathy), or along a series of nerves (a polyneuropathy).

Management

Usually responsive to non-opioid medications.

May not be controlled by non-opioids or opioids; may require adjuvant therapies.

Nurses most often encounter nociceptive pain. However, occasionally a patient may present with neuropathic pain, particularly following a traumatic nerve injury or an inflammation or infection of the CNS. Neuropathic pain requires long-term management strategies.

Pain may also be classified as either: (1) acute, or (2) chronic. Read the information in the following table:

Acute Pain

Chronic Pain

Onset and Duration

Pain which has a sudden onset, but which lasts only as long as it takes the tissue injury to heal.

Pain which may have a gradual or sudden onset, but which lasts longer than it takes for the injury to heal, or well past normal recovery time.

Severity

May be mild, moderate or severe.

May be mild, moderate or severe.

Cause

Generally, a clearly-defined cause, such as an injury or illness.

May not be known, or cause may differ from the cause of the original injury.

Course

Pain gradually resolves as the tissue injury heals.

Pain may not resolve; there are characteristic periods of worsening and improving.

Manifestations

Sympathetic nervous system activation (e.g. increased heartrate, increased respiratory rate, increased blood pressure, diaphoresis, pallour, anxiety, agitation, urine retention).

Behavioural manifestations (e.g. flat effect, decreased physical movement / activity, fatigue, withdrawal, etc.).

Treatment

(1) analgesics for the control of pain, and (2) treatment of the underlying cause of the pain.

Long-term analgesia alongside psychosocial interventions.

Goals of Treatment

Pain control and eventual elimination.

Pain control to the greatest extent possible; enhance function and quality of life.

Nurses will most often encounter acute pain. However, occasionally a patient may present with chronic pain, usually the exacerbation of chronic pain. Chronic pain requires long-term management strategies.

Pain assessment

Rapid pain assessment is completed using the 'OPQRST' mnemonic:

O

Onset: "When did the pain begin?"

P

Provocation and palliation: "What makes the pain worse? What helps the pain?"

Q

Quality: "Describe the pain."

R

Region and radiation: "Where do you feel the pain? Does the pain spread to other areas of your body?"

S

Severity: "On a scale of 1 to 10, where 1 is no pain and 10 is the most severe pain you have experienced, how would you rate the pain?" (Although a range of other pain scales which may be used).

T

Time: "How long has the pain been present?"

This section will cover pain assessment in greater depth. Pain characteristics are very important. This may include asking the patient about:

  • The location of the pain. A patient may not be able to specify where the pain occurs, and even if a location is identified this may not be the site at which the pain originates.
  • The temporal pattern of the pain.
  • The severity of the pain. This is often measured using a pain scale - for example, a numeric scale (0 = no pain, 10 = severe pain) or verbal descriptor scales (e.g. 'none', 'mild', 'moderate', 'severe', etc.).
  • The quality of the pain. Neuropathic pain is often described as 'burning', 'shooting', 'stabbing', 'numbing' or 'itching'. Nociceptive pain is often described as 'aching', 'throbbing' or 'cramping'.
  • Any associated symptoms, such as fatigue, nausea and anxiety, which may exacerbate the pain. Any situations which provoke or palliate the pain.
  • Strategies which the patient has used to manage the pain, and if these are effective.

Pain assessment focuses on speaking with a patient. However, patients may be non-verbal - for example, unconscious, sedated or neurologically impaired. In such cases, observational tools can be used to identify objective signs of pain, often via measurement of the patient's vital signs.

Untreated pain can have many negative impacts upon a patient. It may cause dysregulation in a patient's:

  • Endocrine / metabolic function.
  • Cardiac function.
  • Respiratory system.
  • Genitourinary function.
  • Gastrointestinal function.
  • Musculoskeletal function.
  • Neurologic function.
  • Immunologic function.

Non-verbal patients may also demonstrate their experience of pain in a variety of other ways - for example:

  • Vocalisations.
  • Facial expressions.
  • Noisy and / or laboured breathing.
  • Restlessness, rocking, writhing, clenched fists, rigidity, etc.

On assessment of pain in children: pain is a complex concept, and children may be unable to explain if, where and how they experience pain. There are a number of physical signs that indicate a child may be experiencing pain, for example, a child who cries with:

  • Mouth open and squarish in shape.
  • Brows which are lowered and drawn together, creasing the forehead.
  • Broadening and bulging of the nose.
  • Raising of the tissue on the upper cheeks.
  • Eyes which are squeezed tightly closed.

It is essential to seek information from the parent/s or caregiver/s of a child; these people know the child best, and can best identify what is 'normal' and what is not.

Nurses must also be able to assess pain in older adults. Older adults may consider pain to be a normal, inevitable part of ageing, and may therefore fail to report pain to nurses for fear they will be a 'burden'. The same pain assessment as with adults is used; however, assessment needs to be conducted in an unhurried, supportive manner. 

Pain management

Once pain has been assessed, interventions to manage the pain can be implemented. All pain management follows these general best-practice principles:

  • Pain is a subjective experience; the patient is the best judge of their own pain experience, and must be listened to and believed.
  • Every patient deserves, and has a right to receive, adequate pain management.
  • Both pharmacological and non-pharmacological strategies should be used in combination to achieve the best possible pain relief for the client.
  • Side-effects of pharmacological pain relief must be prevented and / or managed.
  • Ongoing pain management beyond emergency care should be considered.
  • Patient teaching (where appropriate), and the ongoing assessment of the patient's pain.

Interventions selected are based on several factors, including: (1) the type of pain, (2) the severity of the pain, (3) the location and pattern of the pain, (4) associated symptoms and underlying medical conditions, and (5) the patient's preference. Options are described following:

  • Pharmacologic therapy. These are generally divided into three categories: (1) non-opioid analgesics, (2) opioid analgesics, and (3) co-analgesics or adjuvant medications. Mild pain is usually relieved using non-opioid analgesics, however moderate to severe pain usually requires an opioid. Co-analgesic or adjuvant medication may also be required.
  • Non-opioid analgesics: include salicylates, acetaminophen, non-steroidal anti-inflammatory medications (NSAIDS), and cyclo-oxygenase-2 (COX-2) inhibitors. These medications are useful for mild to moderate pain, are typically administered orally, and do not produce tolerance or physical dependence. However, they do have an analgesic ceiling, and gastrointestinal upset is a known side-effect.
  • Opioid analgesics: include μ-agonists, mixed agonist-antagonists, and partial agonists. Used for moderate to severe pain. A variety of known side-effects, including constipation, nausea and vomiting, pruritus and, in severe cases, sedation and respiratory depression. 
  • Co-analgesics or adjuvant medications: may be used alongside other analgesics. Common co-analgesics or adjuvant medications include:
  • Tricyclic antidepressants, which increase the levels of serotonin and norepinephrine in the CNS. Doses required for pain relief are often significantly lower than those used to treat depression.
  • Anti-seizure medications, which are effective for neuropathic pain, and prophylactically for migraines.
  • ą2-adrenergic agonists are often prescribed for chronic and neuropathic pain.
  • Corticosteroids are useful for cancer pain, pain due to spinal cord compression, and inflammatory joint pain. Corticosteroids may have side-effects - including hyperglycaemia, fluid retention, gastrointestinal bleeding, muscle wasting, osteoporosis and adrenal suppression
  • Local anaesthetics -may be used for acute pain and chronic neuropathic pain. Systemic side-effects are rare, however, dysrhythmia has been observed.
  • GABA agonists, such as baclofen, are used for muscle spasm.
  • NMDA antagonists, such as ketamine, which is used for peripheral neuropathic pain. These are rarely seen in emergency care.
  • Mixed μ-agonists opioids and NE/5-HT reuptake inhibitors are used for both nociceptive and neuropathic pain. Their side effects are similar to opioids.

Pharmacological analgesics in emergency care may be administered via a number of different routes, including orally, parenterally, sublingually or buccally, intranasally, rectally, transdermally and / or intraspinally. Not all medications are suitable for administration via all routes; it is essential that nurses refer to drug administration manuals, and follow the policies and procedures.

  • Non-pharmacologic therapies - interventional therapies. These include:
  • Therapeutic nerve blocks, which involve the administration of a local anaesthetic. For severe chronic pain, neuroablative techniques may be used; this involves irreversibly destroying nerve cells.
  • Neuroaugmentation, which involves the electrical stimulation of the CNS to disrupt the transmission of pain signals.
  • Non-pharmacologic therapies - include a range of pain-relieving interventions such as massage, transcutaneous electrical nerve stimulation (TENS), acupuncture, heat therapy and cold therapy. Cognitive therapies, such as distraction, hypnosis and relaxation strategies, may also be used. Evidence for their effectiveness is variable; however, if a patient wishes to use these strategies, they should be supported to do so.

There are a variety of barriers to effective pain management in emergency care. These include fear of tolerance / addiction, concern about side-effects, a desire to be stoic, and ineffective medication dosing regimens. If nurses are aware of these barriers, they can respond effectively to them.

Ethical issues in pain management

There are two key ethical issues associated with pain management with which nurses must be familiar:

  • Fear of tolerance / addiction. Patients and their families / carers may believe that the use of analgesics leads to rapid tolerance and / or addiction. Patients and their families / carers must be assured that, in the short term, the doses provided in emergency care are highly unlikely to result in tolerance or addiction, and that any side-effects can be effectively managed.
  • Fear of hastening death by administering analgesics. It is common for patients and their families / carers to believe that analgesics, may only be given to patients who are terminally ill, and that these medications may hasten their death. Patients and their families / carers must be assured that analgesics are a crucial aspect of pain management, and are used with the aim of providing pain relief and for no other purpose.

Nurses will often care for patients with current or previous substance abuse problems. This abuse may involve opioid analgesics, complicating the management of pain that involves prescription opioids. However, with careful planning, opioids can be used for pain relief effectively and safely in patients with substance abuse problems. An interdisciplinary team should be involved.

Conclusion

This chapter has described the various types and classifications of pain, highlighting those which nurses in emergency care are most likely to encounter. The chapter then comprehensively explained how nurses should assess pain, and it detailed the pain management interventions suitable for the emergency care setting (including pharmacological and non-pharmacological interventions). Finally, this chapter explored some of the ethical issues involved in pain management in the emergency care setting.


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