EMERGENT

Environmentalinteractions

Pain behaviour

Suffering

Pain perception

Nociception

The multi-dimensional approach of pain

Bio-Psycho-Social Model

Why do we bother?

Neuro-endocrineactivation

Other effects

Increasedsympathetic

tone

ion

Sympathetic activation Neuroendocrine activation

Other effects

Pain

Endogenous

opiates

How pain is measured?

1-3 MILD 4-6 MODERATE 7-10 SEVERE

Barfod et al. Scandinavian Journal of Trauma, Resuscitation andEmergency Medicine 2012 20:28

OLD CARS

O- ONSET

L- LOCATION

D- DURATION

C- CHARACTER

A-ALLEVIATING/AGGRAVATING FACTORS ASSOCIATED SYMPTOMS

R- RADIATION

S- SEVERITY

P PALLIATIVE AND PROVOCATIVE FACTORS

Q QUALITY

R RADIATION

S SYMPTOMS ASSOCIATED WITH PAIN

T TIMING

Pain management troubleshooting

Phase Problem

Examination CommunicationBiasDoubts and fears with treatment

Treatment General state of the patientSide effectsKnowledge not satisfactory

Other InexperiencePatient complianceSide effects

JH Burton, J Miner (eds): Emergency seadtion and pain management, Cambridge University Press, 2008

Daily problems of pain management

• Wilson and Pendleton (1989): 56 % of painpatients did not receive painkillers AT ALL !– Only 14 % received painkillers in the first hour

– Most frequent problems:• Inadequate dose: 55%

• i.m. administration: 60 %

• Lewis and Sasater study on 8 ERs:– only 30 % of patients with acute fracture received

painkillers !

ACUTE PAIN MANAGEMENT (emergence)

ASSESSMENT OF PAIN

ACETAMINOPHEN

NSAIDTRAMADOL

OPIOIDSEDATION

ANAESTHESIA

RED FLAGS

Stroke

Subarachnoideal bleeding

Meningitis/encephalitis

Posttraumatic headache

Primary headachesMigraine

•<• Attacks last for 4-72 hours.

• Pain is throbbing, severe and asociated withnausea, vomiting, photo- and phonophobia

• Might present with or without aura.

• No neuro signs

Primary headachesTension headache

• Seen in patients under stress or wrong posture(also in sleep apnoe, caffeine abuse)

• Lasts from 30 minutes to 168 hrs

• Not accompanied by nausea, vomiting, photo-and phonophobia

• On eaxmination: tender neck and headmuscles, otherwise unspecific

Primary headachesCluster headache

• Always unilateral, orbital, supraorbital, temporal or a combination of these

• Very severe, lasts for 15-180 minutes, eperienced 1-8 times/day associated withipyilateral conjunctival injection, lacrimation, nasal stuffing, miosis, ptosis and eyelidoedema

• Unknown etiology

Secondary headaches1. Arteriitis temporalis

2. Epidural and subdural haematoma

3. Headache associated with physical actvity

4. Headache in glaucoma

5. Hypertensive headache

6. Headache asociated with meningitis, encephalitis

7. Sinus thrombosis

8. Stroke:

9. Carbon monoxide poisoning

10. Subarachnoideal bleeding

11. Trigeminal neuralgia

12. Tumor headache

MENINGOCOCCAEMIA

MORTALITY > 70%

CEFTRIAXON - 2G

DEXAMETHASON - 10MG

Acute chest pain

Chest pain

Myocardialischaemia

(50%)

Pulmonarydiseases

(12-14%)

GIT (3-5%)

Psychogenic (9-10%)

Unspecified(15%)

Musculoskeletal

(7%)

ABNORMAL VITAL PARAMETERS SIGNS OF HYPOPERFUSION DYSPNEA ASYMMETRICAL BREATH SOUNDS HEART MURMUR OF LATE ONSET PULSUS PARADOXUS > 10 HGMM

Other common causes of chest pain

Unstable and Prinzmetal angina

Simple pneumothorax/hydro/haemothorax

Inflammatory diseases (lung and the rest)

Musculoskeletal abnormalities

- The differential diagnostics of chest painstarts at triage level benefiting from theadvantages of point-of-care technology

- Since the exact cause of chest pain isfrequently unknown at this stage we mustmonitor and oxygenate our patients! (ECG, BP,SpO2 and 35 % O2).

Chest pain and ECG

• Used for the detection of rhythm disturbances,assessing ventriular and supraventriculardepolarization and/or repolarizationabnormalities

• In ACS diagnostics: repolarization disturbancesare seen as ST changes. Any ST elevation > 0,1 mVin coherent limb leads or > 0,2 mV in coherentchest leads are diagnostic for STEMI.

• NSTEMI: no classical elevation, but ST depression(70-80%), T wave inversion (10-20 %), both ornone of them

ST elevation > 0,1 mVconcordant with the QRS complex (5 points)

ST depression > 0,1 mVin V1, V2, V3 (3 points)

ST elevation > 0,5 mVdiscordant with the QRS complex (2 points)

Score of > 3: STEMI is likely

Biomarkers

Any other biomarkers?

ADMISSION

WORKING DIAGNOSIS

ECG

BIOMARKER

RISK. STRAT.

DIAGNOSIS

TREATMENT

CHEST PAIN

SUSPICION OF ACS

TROPONIN POS.

TROPONIN NEG x2.

HIGH LOW

STEMI NSTEMI UA

REPERFUSION INVASIVE NONINVASIVE

Score-systems

• Used for risk assessment, prediction of severity and etiology of chest pain.

• ACS, STEMI, or NSTEMI: TIMI, a GRACE, orHEART scores (risk stratification based onmulti-parameter assessment)

• Pulmnary embolism: Wells-score (based onclinical data, PMH) helps in further diagnostics(CT) and risk stratification

Case study

• Head-on collision in a lorry with a car – youngmale (passenger)

• Initially no complaints at all than left shoulderpain increasing in intensity

• Helps in extrication of the passangers in thecar

• Pain is getting worse

• Starts to sweat and experiences dyspnea

Abdominal pain

• 10 % of ED visits are due to abdominal pain

• Might reflect simple gastroenteritis but may alsoherald resuscitative states

• Etiology is unknown in 30-40 % but primary aim is to differentiate conditions life threateningconditions requiring emergency surgicalinterventions

• 30 % of cases end up az UDAP (undifferentiatedabdominal pain) 10% of these patients end up inOR

Visceral abdominal painUsually caused by distention of hollow organs or capsular stretching of solid organs. Less commonly by ischaemia or inflammation. May vary from a steady ache or vague discomfort to excruciating or colicky pain. If the involved organ is affected by peristalsis,the pain is often described as intermittent, crampy, or colicky in nature.

Parietal (somatic) abdominal painReults from ischaemia, inflammation or stretching of the parietal peritoneum. Parietalpain, in contrast to visceral pain, often can be localized to the region of the painful stimulus. This pain is typically sharp, knife-like and constant; coughing and moving are likely to aggravate it.

Referred painReferred pain is defined as pain felt at a distance from the diseased organ. It results from shared central pathways for afferent neurons from different locations.

ABDOMINAL AORTIC ANEURYSMÁLIS AORTA ANURIZMA DISSZEKCIÓ/RUPTURA

TRAUMA PERFORÁCIÓ ILEUS MEZENTERIÁLIS TROMBÓZIS

SUDDEN ONSET INTOLERABLE PAIN ASSOCIATED WITH TRAUMA DIFFUSE, BUT INCREASING ASSOCIATED WITH AUTONOMIC

SYMPTOMS SIGNS OF SHOCK SIGNS OF PERITONITIS ABDOMINAL DISTENSION

Abdominal aortic aneurysm

Bowel ischaemia

Bowel obstruction

Trauma

Perforation

Abdominal pain of non-abdominal origin

• Myocardial ischaemia (in the form of epigastrialpain (8%), nausea (38 %), vomiting (11 %) inelderly patients

• Diabetic and alcoholic ketaoacidosis

• Uraemia

• Vasculitis

• Streptococcus pharyngitis

• Methanol and heavy metal poisoning

• Herpes zoster

Physical examination- tricks

• Cough test: due to peritoneal irritation patients are localizing pain whencoughing

• Heel drop test: patients are asked to stand on their toe and than suddenlydrop on their heel – positive in appendicitis

• Murphy sign: patient• abruptly ends deep inspiration during palpation of the RUQ. Murphy’s sign

is very sensitive for acute cholecystitis and biliary colic• Psoas test: having the patient flex the thigh against resistance.• Obturator test: having the patient internally and externally rotate their

flexed hip. Pain elicited by either the psoas or obturator maneuvers can indicate irritation of the respective muscles by an inflammatory process such as acute appendicitis, a ruptured appendix or pelvic inflammatory disease

• Rovsing sign: pain in the RLQ precipitated by palpation of the left lower quadrant. This is also suggestive of appendicitis.

Imaging(US, X-ray, CT)

• FAST

• Deatiled abdo US by radiologists

• X-ray

– Plain abdo: free gas, niveau, distension

• CT

– Gives the most info, might be plain, contrastenhanced, angio CT

Bloods, biomarkers

• FBC

• LFT, U&Es

• Inflammatory markers (PCT, CRP)

• Amylase, lipase

• Lactate

http://misc.medscape.com/pi/android/medscapeapp/html/A433404-business.html

• 53 yr old male, right renal colicky pain

• Slight haematuria, otherwise NAD

• No significant labs

• Pain is increasing in intensity despite adequatepain relief

• While awaiting abdo US PEA develops

Case study

Low back pain

TRAUMA MALIGNANCY IN PMH TEMPEARTURE, CHILLS IMMUNSUPPRESSION PAIN PRSENTINGWHEN LYING OR

AT NIGHT SADDLE-LIKE ANAESTHESIA BLADDER OR ANAL DYSFUNCTION NEUROLOGICAL DEFICIT

ABDOMINÁLIS AORTA ANURIZMA DISSZEKCIÓ/RUPTURA

LOKÁLIS FERTŐZÉS METASZTÁZIS CAUDA EQUINA SY SPINÁLIS GYÖKSÉRÜLÉS

Abdominal aortic aneurysm

Spinal infection

Metatases

Cauda equina syndrome

Spinal root trauma

Useful examinations

• Laségue-jel • FABER (Flexion-ABduction-

External Rotation)- teszt

• Anaesthesia

• Opiates

• NSAIDS, weak opiates

• Adjuvants (SSRI, gabapentin)

• NSAIDS

• Paracetamol, metamizol, ibuprophen

Take home messages

• Pain is a frequent presentingsymptome in emergency care (70%)

• Pain must be dealt with, causes to beclarified!

• Never forget about life threateningconditions presenting with severe pain!

• Pain relief gradually and carefully!