Acute pain is present in 50% to 60% of all emergency department (ED) patients. Procedural sedation and analgesia often is needed for painful interventions or diagnostic studies.
Responses to pain vary and may include increased heart rate, blood pressure, respiratory rate, and behavioral changes. Because subjective impressions may be inaccurate, pain is often assessed with objective scales. Pain relief is a dynamic process and reassessment is mandatory.
Pharmacologic and nonpharmacologic interventions may be helpful for treating anxiety and pain in the ED. Nonpharmacologic interventions include the application of heat or cold, immobilization and elevation of injured extremities, explanation and reassurance, music, biofeedback, guided imagery, and distraction methods, such as feeding sucrose solution to infants. Discussing a painful intervention with a patient immediately before the procedure may decrease the anxiety created by anticipation. When pharmacologic intervention is needed, the selection of agent should be guided by the need for sedation or analgesia, the route of delivery, and the desired duration of effects.
Nonopiate Analgesics, such as acetaminophen, 650 to 1000 milligrams (15 milligrams/kilogram PO or PR in children) or nonsteroidal anti-inflammatory drugs such as ibuprofen, 400 to 800 milligrams PO (10 milligrams/kilogram PO in children) can be used to treat mild to moderate pain. Parenteral NSAIDs are no more effective than oral medications. Adverse effects of NSAIDS include gastrointestinal irritation, renal dysfunction, platelet dysfunction, and impaired coagulation. Aspirin should be avoided in children because of an association with Reye syndrome.
Opiates, such as morphine, 0.1 milligram/kilogram IV (0.1 to 0.3 milligram/kilogram in children), fentanyl, 1.5 micrograms/kilogram IV (1 to 2 micrograms/kilogram in children), and hydromorphone, 0.0125 milligram/kilogram IV (0.015 to 0.020 milligram/kilogram in children) are the agents of choice for moderate to severe pain. Additional doses are given every few minutes at half the original dose until pain is controlled. Side effects of opiates include respiratory depression, nausea and vomiting, confusion, pruritus, and urinary retention. Oral opioids, such as oxycodone, 5 to 10 milligrams PO (0.1 milligram/kilogram/dose in children) or hydrocodone (5 to 10 milligrams PO (0.1 milligram/kilogram/dose) may be tried for pain relief if procedural sedation and analgesia will not be used.
Procedural Sedation and Analgesia (PSA)
The indications for PSA include painful procedures, such as abscess drainage, wound management, tube thoracostomy, orthopedic manipulation, cardioversion, and diagnostic studies. Analgesia is relief from the perception of pain. Minimal sedation is a drug-induced state characterized by normal responses to voice and normal cardiac and ventilatory functions. Moderate sedation and analgesia (conscious sedation) are characterized by responsiveness to voice or light tactile stimulation with normal cardiac and ventilatory functions. Deep sedation and analgesia are characterized by responsiveness to repeated or painful stimulation, potentially inadequate ventilation, and potential loss of protective reflexes. Dissociative sedation is a type of moderate sedation.
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