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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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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
evaluation
Evaluation
  • 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
relative potency estimates
Relative Potency Estimates
  • Basis for selecting appropriate starting dose, changing route of administration, or switching to another opioid
meperidine
Meperidine
  • 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
codeine
Codeine
  • 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

Acetaminophen

NSAIDs

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

Corticosteroids

Other Agents

Ketamine

Nitrous Oxide

Tricyclic Antidepressants

Anticonvulsants

  • Potent inhibitors of inflammation
  • Used for visceral, orthopedic, and neuropathic pain
  • Short-term d/t adverse effects
ketamine
Ketamine
  • “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
elderly
Elderly
  • 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
epinephrine
Epinephrine
  • 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
methemoglobinemia
Methemoglobinemia
  • 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
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
pathophysiology
Pathophysiology
  • 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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