Pharmacologic Pain Management in Emergency Department
SABARIAH FAIZAH JAMALUDDIN1
1EMERGENCY AND TRAUMA DEPARTMENT, SUNGAI BULOH HOSPITAL, Malaysia
Musculoskeletal pain causes a significant disability. Patients who have low pain score are usually less prioritized leading to extended waiting time. Their pain is always underestimated and undertreated. This could be due to disparity of pain perception between the attending doctors and patients confounded by variety spectrum of psychological, sociocultural and situational variables that affect people’s perception and expression of pain. This leads to unresolved pain and causes frequent visits to emergency department and primary health care. Its sequelae, chronic pain and decline in function will result in significant reduction in patient’s quality of life. The aim of ED pain management in musculoskeletal pain is to alleviate pain to an acceptable level for early mobilisation and early discharge so that they can return to their normal daily activities. Assessment of pain score pre and post treatment will guide the attending doctor to deliver an appropriate treatment plan for the pain.
Pain can be acute or chronic, mechanical or inflammatory in origin. Hence, the treatment should be individualized tailored to patient’s needs. Treatment of musculoskeletal pain in ED involved both pharmacological and non-pharmacological depending on the nature of pain. Pharmacological drugs are Non-Steroidal Anti-inflammatory Drugs (NSAIDS), opioids, acetaminophen, inhales such as nitrous oxide and antidepressant such as gabapentin. Classically, pain is treated according to WHO pain ladder and multimodal drug use has given an effective pain control with proven therapeutic benefit and safe as the minimum effective dose of each drug is used for ideal combination. The recently concept termed CERTA (Channels/Enzymes/Receptors Targeted Analgesia) is based on improved understanding of neurobiological aspect of pain. It is part of a multi-modal analgesic strategy which is better than single-agent options. This is due to its synergistic act on different target sites resulting in greater analgesia, reduced dose of each individual medications and lead to fewer side effects (particularly over-sedation) and shorter length of stay.
Procedural sedation and analgesia (PSA) for musculoskeletal pain in ED provides relaxation of the affected muscle groups and the nearby structures reduce patient’s anxiety, and it is particularly important in patients are undergoing ED procedures. The most frequent use agents used for PSA are propofol and ketamine. Ketamine provides excellent sedation and analgesia, and it can be safely used in adults. There are worries over emergence reaction among adults given ketamine for sedation hence small dose of intravenous midazolam may reduce this incident. Other agents used for sedation of patients in the ED include opioids, benzodiazepines, and barbiturate. Other alternative includes the use of regional anaesthesia, topical and intranasal treatment. Intranasal treatment such as use of intranasal fentanyl and ketamine are useful options particularly in prehospital and paediatric settings. Other adjunctive techniques, such as regional, local, and topical anesthesia also provide good analgesic profile. In short, treatment for musculoskeletal pain in ED are diverse. Its use should be tailored to patient’s need and safety profile.