Pain Managing Essay


Affiliate Professor Philip Manning Nestor Consultant Urgent Medicine Section National University, Singapore

Jan 2004

Modified Aug 07 / Feb 08 as well as Nov 09 / December 11 / Dec 12

Accepted practice patterns must be questioned – implementation of pain score to essential signs

We all underestimate the pain produced by common functional procedures

Example – just as we change antibiotics relating to breathing difficulties, perhaps we should be prepared to become more flexible with the pain supervision

We will discuss:

1 . Management of acute soreness in the EMD emphasizing different clinical situations 2 . Procedural sedation (a. k. a conscious

sedation) 3. Management of chronic pain in the EMD


(Wilson JE, Pendleton JM. Oligoanalgesia in the

Unexpected emergency Department. I am J Emerg Med 1989; 7620-623) " OPIOPHOBIA” [Sergey M. Motov & John G. Marshall. Acute Pain Managing Curriculum intended for Emergency Medication Residency Applications. Academic Emergency medicine 2011; 18: S87-S91]

How come this and so when we observe plenty of

people in pain? – it really is, after all, the most common presenting sign at the



Early and appropriate management of discomfort is

essential because: • patients become increasingly more delicate to unpleasant stimulus the longer the pain is usually uncontrolled – a process called " wind-up” • affluence before " wind-up” occurs can potentially decrease subsequent discomfort and pain killer requirements

• incomplete pain alleviation should be the choice of the

affected person, not the physician

" Whose discomfort is it anyway? ”

Pain is a main cause of incomplete or total disability in

industry – it has amazing economic ramifications in terms of healthcare utilization and lost salary

How do you manage

SORENESS in the next conditions

that are frequently experienced in the EDUCATION?

Scenario 1

Scenario a couple of

Scenario 3

Scenario four

Scenario five

Scenario 6th

Scenario six

Scenario almost eight

Scenario on the lookout for

Scenario twelve

Scenario 10

Overview of Pain Management in ED


RICE •Rest •Immobilisation •Cold / Compression •Elevation Shower Parenteral Medicinal Non-parenteral


Blocks: RA, LA

Situation 1 Distal radial crack

Treatment -?

M& 3rd there’s r

Choice: Bier's Block (Intravenous Regional Anaesthesia – IVRA) Suitable for any kind of procedure inc. M& 3rd there’s r on wrist and eloigne forearm

Bier's Block

Contraindications • Uncooperative • As well young: < 10 yrs or < 25 kilogram • Health background: epilepsy, serious hypertension, severe peripheral vascular disease • True allergy to lignocaine Preparation • Past medical history • Targeted examination: baseline BP / CHF • ECG: intended for patients > 60 yrs • Explain procedure to patient • Time out - IPSG # 4

Bier's Block


• Sufferer in monitored area

• Monitors: cardiac monitor, BP, SpO2

• IV cannula in every hand – now questionable

• Apply tourniquet upon affected equip: 50-100 mmHg above SBP • Never forget protective beneath padding

Bier's Block

Technique (cont'd) • Inject 0. 5% lignocaine and take note TIME Draw up 10 multiple listing service of 1% lignocaine with 10 multiple listing service NS (100mg in twenty mls) Harmful dose of lignocaine: a few mg/kg (50kg adult sama dengan 150 mg) Adult: twenty mls Elderly: 15 mls Paeds: 10-15 mls


Blanching of skin can be expected which is indicative of patchy vasoconstriction • Affected person may c/o burning or perhaps ‘heat' inside the arm

Bier's Block

Decrease • Do not deflate cuff if shot time is no more than 20 a few minutes пѓ avoid high attention of lignocaine potentially entering the blood circulation • Age-old technique NOT REALLY evidence-based Relieve • See x 2 hrs

• Check arm or leg circulation……document this

Bier's Obstruct – possible complications

Lignocaine toxicity • Be able to recognize the indicators & symptoms • circumoral numbness

• light headedness

• irrational chat

• unconsciousness

• ringing in ears

• image disturbance

• grand mal seizures

• cardio-respiratory

• slurred talk