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Analgesia, Anesthesia, and Sedation Tintinalli Chap 36, 37, 38, 39. Nicholas Cardinal, DO. Acute Pain. Accompanies 50-60% of ED patient visits in U.S. and Great Britain Pain The physiologic response to a noxious stimulus Accentuated by fear and anxiety Affected by many factors

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Analgesia, Anesthesia, and Sedation Tintinalli Chap 36, 37, 38, 39

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Analgesia anesthesia and sedation tintinalli chap 36 37 38 39

Analgesia, Anesthesia, and SedationTintinalli Chap 36, 37, 38, 39

Nicholas Cardinal, DO

Acute pain

Acute Pain

  • Accompanies 50-60% of ED patient visits in U.S. and Great Britain

  • Pain

    • The physiologic response to a noxious stimulus

    • Accentuated by fear and anxiety

    • Affected by many factors

      • Medical Condition

      • Physical and Emotional Maturity

      • Cognitive State

      • Meaning of Pain

      • Family Attitudes, Culture, and Environment

Peripheral nervous system

Peripheral Nervous System

  • Responsible for somatic pain

  • Registers the original noxious stimulus and conducts it to the CNS

  • Components

    • Primary Afferent Peripheral Nociceptors

    • Dorsal Horn of the Spinal Cord

    • Supraspinal Centers

Pain receptors

Pain Receptors

  • µ1 receptor

    • Stimulation produces supraspinal analgesia, euphoria, miosis, and urinary retention

  • µ2 receptor

    • Stimulation responsible for respiratory depression, gastrointestinal slowing, and cardiovascular slowing

    • Likely source of addiction

  • Κ receptor

    • Stimulation produces dysphoria and spinal-level analgesia



  • Assessment of Pain

    • Non-self-report Measurement

    • Self-report Measurement

      • Adjective Rating Scale

      • Visual Analog Scale

      • Numerical Rating Scale

      • Five-point Global Scale

      • Verbal Quantitative Scale

      • Global Satisfaction Question

Non self report measurement

Non-self-report Measurement

  • More useful as confirmatory tool than as primary assessment tool

    • Physiologic parameter variation

      • Respiratory

      • Cardiovascular

    • Changes in expression and movement

Self report measurement

Self-report Measurement

  • Mainstay of pain assessment

  • Needs to be applied at onset of intervention and then re-evaluated frequently

  • Value assigned by patient should be used as a reference point on which to base pain control

Unique patient populations

Unique Patient Populations

  • Difficulty communicating places patients at risk for inadequate pain management

    • Cognitively impaired

    • Psychotic

    • Extremely young or old

    • Language Barriers

    • Extreme cultural or educational disparity

Modalities of pain management

Modalities of Pain Management

  • Pharmacologic

  • Nonpharmacologic

  • Cognitive-behavioral

  • Physical techniques

Pharmacologic modalities

Pharmacologic Modalities

  • Opioids

  • NSAIDs

  • Acetaminophen

  • Adjuncts

    • Anxiolytics

    • Antiemetics

Severity of pain

Severity of Pain

  • Mild

    • NSAIDs

  • Moderate to Severe

    • Systemic opioids and/or NSAIDs

    • Local or Regional Neural Blockade

Opioid agonists

Opioid Agonists

Relative potency estimates

Relative Potency Estimates

  • Basis for selecting appropriate starting dose, changing route of administration, or switching to another opioid



  • Once the mainstay of pain management in EDs

  • Should no longer be used for acute pain management

  • Is the lowest potency opioid and is often underdosed

  • Metabolite has been shown to cause CNS toxicity in patients with compromised renal function or who are taking MAOIs

  • Metabolite can produce prolonged states of sedation of up to 48 hours

  • Reported to produce more euphoria and may have an increased risk of addiction



  • Standard dose produces little analgesic effect above that of acetaminophen or NSAIDs

  • Produces more nausea, vomiting, and dysphoria

Adverse effects of opioids

Adverse Effects of Opioids

  • N/V

  • Constipation

  • Pruritus

  • Urinary retention

  • Confusion

  • Respiratory Depression

Analgesic adjuncts

Analgesic Adjuncts

  • May provide pain relief at lower opiate dose

    • Anxiolytics

      • Not recommended

      • Synergy with opiates can produce additive adverse effects

    • Antiemetics

      • May potentiate opiates

Nonopioid agents

Nonopioid Agents



Analgesic and anti-inflammatory

Have significant opioid dose-sparing effects

Adverse effects include platelet dysfunction, impaired coagulation, and gastrointestinal irritation and bleeding

Acute Renal Failure in elderly, volume depleted

  • Mild to moderate pain

  • Is not an anti-inflammatory and does not affect platelet aggregation

  • No change required for renal or mild hepatic impairment

Nonopoid agents

Nonopoid Agents


Other Agents


Nitrous Oxide

Tricyclic Antidepressants


  • Potent inhibitors of inflammation

  • Used for visceral, orthopedic, and neuropathic pain

  • Short-term d/t adverse effects



  • “Dissociative” anesthetic

  • Causes minimal respiratory depression

  • Good for brief minor procedures

  • Adverse effects include elevated ICP, elevated intraocular pressure, hypersalivation, and reemergence phenomena

  • Avoid in closed head injury or suspected elevated ICP

Nitrous oxide

Nitrous Oxide

  • Fast onset, short acting

  • Sedative analgesic

  • Inhalational

  • Useful in wound dressing and brief, minor procedures

  • Contraindications include altered mental status, head injury, suspected pneumothorax, and perforated abdominal viscus

Basic dosing guidelines

Basic Dosing Guidelines

  • Titrate dose toward desired effect while minimizing unwanted effects

  • Decrease initial dosing in setting of comorbidity

    • Altered mental status

    • Hemodynamic instability

    • Respiratory dysfunction

    • Multisystem trauma



  • May have more than one source of pain

  • Comorbidities

  • At increased risk for drug-drug interaction

  • More sensitive to analgesic effects, sedation, respiratory depression, and cognitive and neuropsychiatric dysfunction

Dosing adjustments

Dosing Adjustments

  • Renal and Hepatic Dysfunction

  • Respiratory Insufficiency

    • COPD

    • Cystic fibrosis

    • Neuromuscular Disorders

      • Muscular Dystrophy

      • Myasthenia Gravis

  • Drug Interactions

    • Anxiolytics

      • Synergistic sedative effects

    • Monoamine Oxidase Inhibitors

      • Fatal reactions with meperidine

    • Tricyclic Antidepressants

      • May increase morphine levels

  • Nonpharmacologic modalities

    Nonpharmacologic Modalities

    • Heat/cold application

    • Immobilization and elevation of injured extremities

    • Cognitive-Behavioral techniqes

    • Transcutaneous Electrical Nerve Stimulation

    • Acupuncture

    Pain management in trauma

    Pain Management in Trauma

    • Closed Head Injury

      • Must allow for continuous monitoring of neurovascular status

      • Maximal use of regional and nonpharmacologic modalities

    • Minor Trauma

      • NSAID use remains controversial d/t bleeding risk and acute renal failure in the volume depleted patient

    • Limb Injury

      • Continuous monitoring of neurovascular status

    Local anesthesia

    Local Anesthesia

    • Cocaine

      • First isolated in Europe between 1859-1860

      • Toxic and addictive effects were rapidly noticed resulting in patient deaths and addicted medical staff

    • Ester Local Anesthetics

      • Tropocaine

      • Eucaine

      • Benzocaine

      • Procaine

      • Tetracaine

  • Amide Local Anesthetics

    • Lidocaine

    • Mepivacaine

    • Prilocaine

    • Bupivacaine

  • Local anesthetic agents

    Local Anesthetic Agents

    • Synthetic drugs derived from cocaine

    • Weak bases supplied in an acidic solution

    • Anesthetic action produced by drug molecules interrupting and temporarily stopping conduction



    • Acts through vasoconstriction

    • Avoided in end-arterial field

    • Advantages

      • Provides longer duration of anesthesia

      • Promotes wound hemostasis

      • Slows systemic absorption

      • Decreases potential for toxicity

      • Allows greater volume to be used for extensive laceration repair

    Toxicity of local anesthetics

    Toxicity of Local Anesthetics

    • Related to potency and duration of action

    • Serious adverse reactions more common in amides than the esters

    • Enhanced by hypercarbia, hypoxemia, and acidosis

    • Usually due to inadvertent IV injection or excessive dose

    Cns toxicity

    CNS Toxicity

    • Due to conduction block

    • Directly related to lipid solubility

    • Symptoms range from perioral tingling and numbness to confusion, seizure and coma

    • Seizure activity is a warning for impending ventricular arrhythmias and cardiovascular collapse

    Cardiovascular toxicity

    Cardiovascular Toxicity

    • Dose-dependent

    • Mediate through sodium channel blockade within the heart

    • Worsened by pregnancy

    • Effects include myocardial depression and ventricular dysrhythmias

    • Bupivacaine has highest incidence and is contraindicated for use in regional anesthesia



    • Prilocaine and benzocaine cause oxidation of ferric form of hemoglobin to ferrous form

    • Visible cyanosis results when concentration exceeds 1.5 g/dL

    • Usually benign

    Amide local anesthetics

    Amide Local Anesthetics

    • Lidocaine

      • Most commonly used anesthetic in the ED

      • Excellent efficacy and low toxicity profile

      • Rapid onset and intermediate duration of action

    • Prilocaine

      • Low CV toxicity profile

      • May cause methemoglobinemia after large IV bolus

      • Used with lidocaine in EMLA cream

    • Bupivacaine

      • Slow onset and long duration of action

      • High CV toxicity potential

      • Use in prolonged procedures or when longer postprocedural anesthesia is required

    • Mepivacaine

      • Rapid onset and intermediate duration of action

      • Intermediate toxicity

    Ester local anesthetics

    Ester Local Anesthetics

    • Procaine

      • Slow onset

      • Short acting

      • Very short half-life

    • Tetracaine

      • Slow onset

      • Long duration of action

      • Injectable for spinal anesthesia

      • Topical for use on eye, mucous membranes, and skin

    Alternative agents

    Alternative Agents

    • Diphenhydramine

      • Effective local anesthetic

      • Injection more painful than lidocaine

      • Can cause tissue irritation and skin necrosis

    • Benzyl Alcohol

      • As effective as lidocaine

      • Short duration usually requiring additional injections during procedure

    Local anesthetic infiltration

    Local Anesthetic Infiltration

    • Most common use of local anesthetics in ED

    • Rapid onset

    • Low risk of systemic toxicity

    • Used for wound repair and invasive procedures

    • Lidocaine for short procedures and bupivacainefor longer procedures

    Minimizing pain of infiltration

    Minimizing Pain of Infiltration

    • 27- or 30-gauge needle

    • Deep, slow infiltration

    • Buffered lidocaine

      • Sodium bicarbonate reduces pain

    • Warm lidocaine

      • 37-42 degrees C

    • Injection through wound margins

    • Distraction techniques

    Topical anesthetics

    Topical Anesthetics

    • Used to reduce discomfort of local procedures

    • Work better on head and neck than extremities

    • Advantages

      • Painless

      • Do not distort wound edges

      • May provide good hemostasis if formulation includes a vasoconstrictive agent

    Topical anesthetics1

    Topical Anesthetics

    • TAC

      • 0.5% Tetracaine, 0.05% Adrenaline, 11.8% Cocaine

      • Other mixtures are cheaper, have less toxicity, and do not contain a controlled substance

    • LET

      • 4% Lidocaine, 0.1% Epinephrine, 0.5% Tetracaine

      • Prepared in single-use 5-ml vials

      • Applied directly to wound for 20-30 minutes

      • Avoid contact with mucous membranes, fingers/toes, ear pinna, penis, and tip of nose

    Topical anesthetics2

    Topical Anesthetics

    • EMLA

      • Eutectic Mixture of Local Anesthetics (2.5% Lidocaine and 2.5% Prilocaine)

      • Available preparation is nonsterile and should only be applied to intact skin

      • Applied directly to skin and covered with occlusive dressing

      • Analgesia at 1 hour, peak at 2 hours

    • Lidocaine

      • Available in solution, ointment, cream and jelly preparations

      • Commonly used to facilitate placement of urinary catheters, nasogastric tubes, and fiberoptic scopes

    Other topical anesthetic agents

    Other Topical Anesthetic Agents

    • Benzocaine

      • Used for mucosal anesthesia to relieve pain from oral ulcers, wounds, inflammation and to facilitate passage of nasogastric tubes or endoscopy

    • Iontophoresis

      • Delivery of topical anesthetic with mild electrical current

    • Ethyl Chloride

      • Skin refrigerant or vapocoolant delivered by a spray

      • Causes anesthesia for 30-60 seconds

      • Not for use on mucosal surfaces

    Regional anesthetic procedures

    Regional Anesthetic Procedures

    • Can minimize opiate use

    • Decreases need for procedural sedation

    • Should be administered in lowest dosage that results in an effective block

    • Epinephrine can be added to enhance duration, efficacy, reliability, and safety

    Peripheral nerve blocks

    Peripheral Nerve Blocks

    • Advantageous for procedures on the digits, hand, and foot

    • Require less total anesthetic

    • Often less painful than local infiltration

    • Onset of anesthesia may be up to 15 minutes

    • Document neurovascular status prior to block

    • Complications include nerve injury and systemic toxicity

    Wrist blocks

    Wrist Blocks

    • Used for lacerations of the hand

    • Median Nerve

    • Ulnar Nerve

    • Radial Nerve

    Digital nerve block

    Digital Nerve Block

    • More rapid onset than metacarpal block

    • Used for laceration repair, I&D of paronychia, or finger/toenail removal

    • Large volumes of anesthetic can result in compartment syndrome

    Foot blocks

    Foot Blocks

    • Anesthesia for surgical procedures of the foot

    • Sensation to foot supplied by 5 different nerves

      • Posterior Tibial Nerve

      • Sural Nerve

      • Saphenous Nerve

      • Superficial Peroneal Nerve

      • Deep Peroneal Nerve

  • Most blocks involve at least 2 nerves

  • Contraindications include peripheral vascular disease and traumatic circulatory compromise

  • Facial and oral blocks

    Facial and Oral Blocks

    • Anesthesia to commonly injured areas

      • Forehead, chin, lips, nose, tongue, ear

  • Often require blockade of more than one nerve

  • Topical EMLA cream or refrigerant sprays should be applied prior to injection

  • 2% lidocaine can be applied to oral mucosa

  • Avoid direct infiltration of pinna d/t risk of tissue necrosis

  • Femoral nerve block

    Femoral Nerve Block

    • Effective for relieving pain of femoral neck fracture

    • Useful in multiple trauma patient

    Intercostal block

    Intercostal Block

    • Management of pain following chest trauma or from a chest tube

    • Contraindications include local soft tissue disease and contralateralpneumothorax

    • High systemic absorption and toxicity

    Hematoma blocks

    Hematoma Blocks

    • Simple, quick, and effective for closed fracture reduction

    • Not as efficacious as IV Regional (Bier’s) Block

    Intravenous regional block bier s

    Intravenous Regional Block (Bier’s)

    • IV infusion of local anesthetic distal to an inflated pneumatic tourniquet

    • Used for fracture reductions, large laceration repair, and foreign body removal

    • Most commonly used for upper extremity procedures

    • Duration is 30-60 minutes

    • Requires continuous monitoring and patient NPO for 4 hours

    • Contraindications include peripheral vascular disease, raynaud syndrome, sickle cell disease, cardiac conduction abnormalities, hypertension, cellulitis, and children under 5

    Levels of sedation

    Levels of Sedation

    • Minimal Sedation

      • drug-induced anxiolysis

      • Patient responds normally to verbal commands

      • Cognitive function and coordination may be impaired

      • Ventilatory and cardiovascular function is unaffected

    • Moderate Sedation and Analgesia

      • PSA or “conscious sedation”

      • Drug-induce depression of consciousness

      • Patient responds purposefully to verbal commands alone or with light tactile stimulation

    • Deep Sedation and Analgesia

      • Patient cannot be easily aroused but responds purposefully after repeated or painful stimulation

      • May require assistance in maintaining patent airway and spontaneous ventilation may be inadequate

    • Anesthesia

      • Drug-induced loss of consciousness

      • Patient cannot be aroused even with painful stimulation

      • Requires assistance in maintaining a patent airway and may need positive pressure ventilation

      • Cardiovascular function may be impaired

    Procedural sedation and analgesia

    Procedural Sedation and Analgesia

    • Indications

      • Treatment of severe pain

      • Attenuation of pain and anxiety associated with procedures

      • Rapid tranquilization

      • Need to perform a diagnostic procedure

    • Agents

      • Often have narrow therapeutic index

      • Should be given in small incremental doses

    • Monitoring

      • Should be performed by another provider who understands the pharmacology, possesses sound airway-management skills, and will not be distracted by other tasks

    Patient assessment

    Patient Assessment

    • Classification

      • I

        • Normal healthy patient

      • II

        • Mild systemic disease

          • Asthma

          • Controlled diabetes

      • III

        • Moderate systemic disease

          • Stable angina

          • Diabetes with hyperglycemia

          • Moderate COPD

    • IV

      • Severe systemic disease

        • Unstable angina

        • DKA

    • V

      • Moribund

    • +E

      • All ED patients

    Agents in psa

    Agents in PSA

    • Opioids

      • Morphine

      • Fentanyl

  • Anxiolytics

    • Midazolam

  • Anesthetic Agents

    • Propofol

    • Etomidate

    • Ketamine

    • Methohexital

  • Midazolam


    • Benzodiazepine

      • potentiate inhibitory activity of GABA in CNS

      • Result in sedation, amnesia, anxiolysis, respiratory depression, and anticonvulsant effects

    • Use cautiously in combination with alcohol or opioids d/t increased sedative and respiratory-depressant effects

    Antidotal agents

    Antidotal Agents

    • Naloxone

      • Competitive opioid antagonist at µ receptors

      • Indicated for reversal of unwanted respiratory depression after opioid administration

      • May not reverse fentanyl-induced chest wall rigidity

      • Patients who are opioid dependent may develop withdrawal with large doses

    • Flumazenil

      • Competitive antagonist of benzodiazepines

      • Use with caution in benzodiazepine-dependent patients

      • Indicated for reversal of respiratory depression caused by benzodiazepines

    Chronic pain

    Chronic Pain

    • Painful condition lasting longer than 3 months, persists beyond the reasonable time for an injury to heal, or persists 1 month beyond the usual course of an acute disease

    • 4 Types

      • Pain persisting beyond the normal heal time for a disease or injury

      • Pain related to a chronic degenerative disease or persistent neurologic condition

      • Cancer-related pain

      • Pain that emerges or persists without an identifiable cause

    Chronic pain1

    Chronic Pain

    • Affects approximately 1/3 of U.S. population at least once during an individual’s lifetime

    • Estimate annual cost of 80-90 billion dollars

    Causes of chronic pain

    Causes of Chronic Pain

    • Chronic pathologic process in the musculoskeletal or vascular system

    • Chronic pathologic process in one of the organ systems

    • Prolonged dysfunction in the peripheral or central nervous system

    • Psychological or environmental disorder



    • 3 Types of Chronic Pain

      • Nociceptive associated with ongoing tissue damage

        • Cancer

        • Chronic pancreatitis

      • Neuropathic pain associated with nervous system dysfunction

        • Complex Regional Pain type II

        • Postherpetic neuralgia

        • Phantom Limb Pain

      • Psychogenic pain

        • No identifiable cause

        • Diagnosis of exclusion

    Associated conditions

    Associated Conditions

    • Myofascial Headache

      • Variant of tension headache

      • Presence of trigger points on the scalp

      • Pain is constant, squeezing, and occasionally shooting

      • Neck pain/stiffness; N/V

    • Transformed Migraine

      • Classic migraine headaches change over time

      • One cause is frequent treatment with opioids

      • Vascular symptoms become predominantly muscular symptoms

      • Pain is nonthrobbing, squeezing, bandlike

      • Antimigraine medications fail to work

    Associated conditions1

    Associated Conditions

    • Fibromyalgia

      • Symptoms persist greater than 3 months

      • Presence of 11 of 18 specific tender points

      • Non-restorative sleep

      • Muscle stiffness

      • Generalized aching pain

    • Chronic Myofascial Chest Pain

      • Dull, constant pain

      • Trigger points on chest wall

    Associated conditions2

    Associated Conditions

    • Back Pain

      • Types

        • Myofascial

          • Constant, dull, and occasionally shooting pain

          • Does not follow classic nerve distribution

          • May be exacerbated by movement

          • Usually have trigger points at site of greatest pain

          • No muscle atrophy or weakness

        • Articular

          • Constant, sharp pain

          • Exacerbated by movement

          • Associated with local muscle spasm

        • Neurogenic

          • Burning, shooting, or aching pain

          • Constant or intermittent

          • Usually more severe in the leg than the back

          • Follows a dermatome

          • May have muscle atrophy and reflex changes

    Associated conditions3

    Associated Conditions

    • Complex Regional Pain

      • Symptoms

        • Allodynia

        • Persistant burning or shooting pain

      • Type I (Reflex Sympathetic Dystrophy)

        • d/t prolonged immobilization or disuse

      • Type II (Causalgia)

        • d/t peripheral nerve injury

    Associated conditions4

    Associated Conditions

    • Postherpetic Neuralgia

      • Follows course of an acute episode of herpes zoster in 8-70% of cases

      • Increased incidence with advancing age

      • Symptoms include allodynia, shooting and lancinating pain, hyperesthesia in involved dermatome

    • Phantom Limb Pain

      • More frequent in patients who had pain in the extremity prior to amputation

      • Aching, cramping, burning, tearing, or squeezing pain

      • Often does not respond to any treatment

    Treatment of chronic pain

    Treatment of Chronic Pain

    • Opioids

      • Should only be used if they enhance function at home and at work

      • One physician should be the sole prescriber

    • NSAIDs

      • More helpful in acute than in chronic pain

    • Antidepressants

      • Amitriptyline

    Treatment of chronic pain1

    Treatment of Chronic Pain

    • Anticonvulsants

      • Useful for neuropathic pain

        • Carbamazepine

        • Clonazepam

        • Gabapentin

    • Other Agents

      • Calcitonin

      • Prednisone

      • Muscle Relaxants

      • Tramadol

    Chronic pain in the elderly

    Chronic Pain in the Elderly

    • Doses should be reduced to avoid side effects

      • NSAIDs

        • GI bleeding

        • Renal disease

      • Opioids

        • Debilitating sedation

        • Constipation

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