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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!
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