Review on pharmacological pain management in trauma patients in (pre‐hospital) emergency medicine in the Netherlands

Pain is one of the main complaints of trauma patients in (pre‐hospital) emergency medicine. Significant deficiencies in pain management in emergency medicine have been identified. No evidence‐based protocols or guidelines have been developed so far, addressing effectiveness and safety issues, taking the specific circumstances of pain management of trauma patients in the chain of emergency care into account. The aim of this systematic review was to identify effective and safe initial pharmacological pain interventions, available in the Netherlands, for trauma patients with acute pain in the chain of emergency care. Up to December 2011, a systematic search strategy was performed with MeSH terms and free text words, using the bibliographic databases CINAHL, PubMed and Embase. Methodological quality of the articles was assessed using standardized evaluation forms. Of a total of 2328 studies, 25 relevant studies were identified. Paracetamol (both orally and intravenously) and intravenous opioids (morphine and fentanyl) proved to be effective. Non‐steroidal anti‐inflammatory drugs (NSAIDs) showed mixed results and are not recommended for use in pre‐hospital ambulance or (helicopter) emergency medical services [(H)EMS]. These results could be used for the development of recommendations on evidence‐based pharmacological pain management and an algorithm to support the provision of adequate (pre‐hospital) pain management. Future studies should address analgesic effectiveness and safety of various drugs in (pre‐hospital) emergency care. Furthermore, potential innovative routes of administration (e.g., intranasal opioids in adults) need further exploration.     

Clinical tools for the assessment of pain in sedated critically ill adults

Aim: This paper aims to review the evidence regarding pain assessment tools for sedated patients and to establish whether the use of a tool can be recommended in practice. Background: Pain assessment is a challenging area of critical care nursing practice, particularly among sedated patients. Tools to aid in assessing pain among this patient group have been developed and tested recently. Search strategy: In this systematic review five papers that tested pain assessment tools for sedated patients are discussed. These papers were identified via the CINAHL and MEDLINE databases using the search terms: ‘pain assessment’ and ‘sedated’ or ‘unconscious’ or ‘critically ill’ or ‘critical illness’ or ‘critical care’. Conclusions: The Behavioural Pain Scale (BPS) has been tested among the broadest range of patients and was found to be a reliable and valid tool in three studies. Research is needed to further demonstrate the reliability and validity of the Critical‐Care Pain Observation Tool (CPOT), as the paper of Gelinas et al. did not test its internal consistency and domain structure. The CPOT also needs testing among different critical care populations. The design of Odhner et al. study did not allow adequate testing of the Non‐verbal Pain Scale (NVPS). Implications for practice: The implementation of the BPS can be recommended in intensive care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions. The CPOT may also prove useful in assessing pain among sedated patients, but first requires further validation. Also, further research is needed into the effects of pain assessment tools on pain management practices and patient outcomes.     

Etiology of non-traumatic acute abdomen in pediatric emergency departments

Acute abdominal pain is a common complaint in pediatric emergency departments. A complete evaluation is the key factor approaching the disease and should include the patient’s age, any trauma history, the onset and chronicity of the pain, the related symptoms and a detailed physical examination. The aim of this review article is to provide some information for physicians in pediatric emergency departments, with the age factors and several causes of non-traumatic acute abdominal pain. The leading causes of acute abdominal pain are divided into four age groups: infants younger than 2 years old, children 2 to 5, children 5 to 12, and children older than 12 years old. We review the information about acute appendicitis, intussusception, Henoch-Schönlein purpura, infection, Meckel’s diverticulum and mesenteric adenitis. In conclusion, the etiologies of acute abdomen in children admitted to the emergency department vary depending on age. A complete history and detailed physical examination, as well as abdominal imaging examinations, could provide useful information for physicians in the emergency department to narrow the differential diagnosis of abdominal emergencies and give a timely treatment.     

Predictors for opioid analgesia administration in children with abdominal pain presenting to the emergency department

OBJECTIVES: Abdominal pain is one of the most common symptoms in children. The aim of this study was to determine the rate of opioid analgesia in children with abdominal pain presenting to the pediatric Emergency Department (ED) and to identify factors associated with administration of opioids. METHODS: We retrospectively reviewed all charts of patients with abdominal pain < 7 days presenting to the ED of a tertiary pediatric hospital over a 3-month period. Demographic and illness-related variables were recorded, and the primary outcome variable was whether opioid analgesia was used to relieve abdominal pain. We analyzed the data with a univariate analysis and a multivariate stepwise regression analysis to determine independent influences on the rate of opioid prescribing. RESULTS: Of 582 children included in the analysis, 53 (9%) received opioid analgesia. Pain in the right lower quadrant on examination, documentation of a pain score in triage, and the level of acuity as determined by the triage nurse were predictors of administration of opioids by the physician. Thirty-four (77%) of the opioids given were below the recommended dose for the child. CONCLUSIONS: Few pediatric patients with abdominal pain are treated with pain medications. The decision to use opioid analgesia for acute abdominal pain in the pediatric ED is influenced by acuity level, pain score documentation in triage, and location of abdominal pain. Efforts should be made to educate physicians on the appropriate administration and dose of opioids in children with abdominal pain in the ED.     

Acute Pain and Availability of Analgesia in the Prehospital Emergency Setting in Italy: A Problem to be Solved

Objectives:   The treatment of acute pain in the prehospital emergency setting remains a significant problem. We evaluated the incidence, site, and possible cause of acute pain in the prehospital period and also the current state of prehospital pain management by evaluating analgesic availability in emergency vehicles in Italy.
Methods:   First aid volunteers documented the presence, intensity, and site of acute pain by questionnaire for over 3 months. Emergency service operations completed a questionnaire on analgesic availability in ambulances and helicopters.
Results:   Pain symptoms were present in two-thirds of the patients ( n  = 383) and ranked as moderate to unbearable in 41.75%. Results of the analgesic availability survey indicate that 10.6% of the ambulance services carry no pain killers (including non-steroidal anti-inflammatory drugs [NSAIDs] and/or paracetamol) and 11.5% are without an opioid. The emergency helicopter survey showed a significant difference in analgesic availability compared with ambulances, with 97.6% having at least one opioid agent available (weak or strong). A wide geographical variation in the availability of analgesic agents in ambulance and helicopter services was seen.
Conclusions:   There is a high prevalence of pain among patients receiving prehospital emergency treatment in Italy and treatment for acute pain during emergency treatment of trauma patients is inadequate. All emergency vehicles, without distinction, should carry opioids and other analgesic drugs (NSAIDs and paracetamol) and there should be no geographic differences in the availability of pain medications.     

急诊腹痛症状早期预警方法研究进展

急诊科就诊患者较多、拥挤是普遍现象,其中需要紧急救治的患者常常被延误治疗。医师延误对病情的评估、疾病的诊断和治疗,将导致不良结局的出现。腹痛占急诊就诊的6.8%,是急诊患者的最常见临床症状,其诊断繁多,包括良性疾病和威胁生命的疾病〔1〕。由于不同的腹痛病因引起的临床特点不同,从而使急诊医师更多地依赖于实验室检查。一项对急诊的研究表明,65%的相同的非创伤性腹痛患者至少要接受一项影像学检查〔2〕。实验室检查不仅增加了开销,延长了留观时间,而且加重了急诊室的拥挤现象。有调查显示,在过去     

Hot Off the Press: A Systematic Review And Meta‐analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department

Ketamine has been studied as an alternative to opioids for acute pain in the emergency department setting. This review compares the effectives of intravenous ketamine at a dose of <0.5mg/kg to opioids for acute pain in adult patients. Measurements were taken within 60 minutes of administration. Ketamine was found to have similar effectiveness to opioids. Increased, but short‐lived, side effects were seen with ketamine.     

Spontaneous Perforation of Acalculous Gall Bladder Presenting as Acute Abdomen

Background

Acute abdominal pain is commonly encountered in the emergency department (ED), but a diagnosis of gall bladder perforation (GBP) is rarely considered in the absence of predisposing factors.

Objectives

This article will highlight the risk factors, diagnosis, and management of GBP, a rare but potentially life-threatening biliary pathology.

Case Report

A 73-year-old diabetic man presented to the ED with a 12-h history of severe upper abdominal pain. He was hemodynamically stable, but abdominal examination showed distention, guarding, and diffuse tenderness. Abdominal X-ray study showed mildly distended small bowel loops without any air-fluid levels. Abdominal sonography revealed mild ascites and pericholecystic fluid collection but no gall bladder calculi. Laboratory reports documented a white blood cell count of 13,700/mm³ and elevated serum amylase of 484 IU/L. A contrast-enhanced computed tomography (CT) scan of the abdomen suggested discontinuity of the gall bladder wall along with fluid accumulation in the pericholecystic, perihepatic, right subphrenic, and right paracolic spaces. In view of the possibility of spontaneous GBP developing as a complication of acute acalculous cholecystitis, laparotomy was planned. At surgery, several liters of bile-stained peritoneal fluid were aspirated and inspection of the gall bladder revealed a perforation at the fundus. After cholecystectomy, the patient had an uneventful recovery.

Conclusion

The diagnosis of spontaneous gall bladder perforation should be considered in elderly patients presenting to the ED with symptoms and signs of peritonitis even in the absence of pre-existing gall bladder disease. Abdominal CT scan is an invaluable tool for the diagnosis, and early surgical intervention is usually life-saving.     

Ceftriaxone‐associated biliary pseudolithiasis in children: do we know enough?

Ceftriaxone is an antibiotic agent frequently used in paediatric hospital practice for the treatment of severe bacterial infections. The use of this agent can result in cholelithiasis and/or biliary sludge, more commonly in children than in adults. This systematic review was aimed at analysing available literature concerning ceftriaxone‐associated biliary pseudolithiasis in paediatric patients, with a special emphasis on the clinical aspects. A literature analysis was performed using Medline and Embase electronic databases (articles published in English up to December 2019), with the search terms and combinations as follows:’ceftriaxone’, ‘cholelithiasis’, ‘biliary sludge’ ‘gallstones’ ‘neonates’ ‘children’ ‘clinical aspects’ ‘management’. Several case reports, case series and prospective/retrospective studies have documented a relationship between ceftriaxone treatment and biliary pseudolithiasis in the paediatric population, even though literature data regarding neonates and infants are scarce. Ceftriaxone‐associated biliary pseudolithiasis is dose‐dependent and usually asymptomatic but, sometimes, it may present with abdominal pain, nausea and emesis. Abdominal ultrasonography should be performed when this complication is suspected. Generally, ceftriaxone‐associated cholelithiasis resolves over a variable period of time (days to months) after cessation of therapy. Therefore, a conservative approach to this condition is advocated, but a prolonged follow‐up may be necessary. A personalized assessment of factors predisposing to ceftriaxone‐associated biliary pseudolithiasis before prescribing the drug can allow to minimize the risk of developing it, with significant advantages in terms of human and economic costs.     

Evaluation and management of acute pancreatitis

Acute pancreatitis(AP) is one of the most common gastrointestinal causes for hospi-talization in the United States. In 2015, AP accounted for approximately390000 hospitalizations. The burden of AP is only expected to increase over time.Despite recent advances in medicine, pancreatitis continues to be associated with a substantial morbidity and mortality. The most common cause of AP is gallstones, followed closely by alcohol use. The diagnosis of pancreatitis is established with any two of three following criteria:(1) Abdominal pain consistent with that of AP;(2) Serum amylase and/or lipase greater than three times the upper limit of normal; and(3) Characteristics findings seen in crosssectional abdominal imaging. Multiple criteria and scoring systems have been established for assessing severity of AP. The cornerstones of management include aggressive intravenous hydration, appropriate nutrition and pain management.Endoscopic retrograde cholangiopancreatography and surgery are important aspects in management of acute gallstone pancreatitis. We provide a comprehensive review of evaluation and management of AP.     

The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine

Background

Pain is one of the most common reasons patients present to the emergency department (ED). Emergency physicians should be aware of the numerous opioid and nonopioid alternatives available for the treatment of pain.

Successful emergency pain control for acute pancreatitis with ultrasound guided erector spinae plane blocks

Pain control for patients in the Emergency Department (ED) with acute pancreatitis (AP) can be difficult and is often limited to intravenous opioids. The acute side effects from opioids are well known and their use in the treatment of AP is associated with prolonged length of hospitalization. Additionally, up to 10% of patients hospitalized for acute pancreatitis are still receiving opioids 6 months after discharge. Ultrasound-guided regional anesthesia by emergency physicians has increasingly proven to be an integral part of a multi-modal opioid sparing pain control strategy for patients in the ED. The ultrasound guided erector spinae plane block may be an ideal adjunct or alternative to opioids for analgesia from AP in the ED. The erector spinae plane block has already been successfully utilized by emergency physicians for pain control from rib fractures, herpes zoster, and more recently, acute appendicitis A lower thoracic erector spinae plane block targets sympathetic nerve fibers in addition to the dorsal and ventral rami via local anesthetic spread to the paravertebral space to provide both visceral and somatic analgesia. Herein, we present the first reported case of acute pancreatitis pain successfully managed by emergency physicians with the ESPB.     

Critical pancreatitis management associated with hypertriglyceridemia in pregnancy in emergency service

Because of the variable clinical features of acute pancreatitis, it is difficult to make a differential diagnosis in patients presenting with abdominal pain in emergency departments. Acute pancreatitis due to severe hypertriglyceridemia during pregnancy is rare but due to the increased risk of maternal and fetal mortality, diagnosis and treatment options should be known and should be performed in the emergency department, which is the first admission site.In this case report, we present a 20-year-old woman with 19 weeks pregnant who presented to the emergency department with abdominal pain and whose biochemistry parameters were high enough to give lipemic stimulation was hospitalized in the emergency ıntensıve care unit (EICU) in the emergency department and lipid apheresis treatment was planned successfully. Lipid apheresis treatment in patients with resistant hypertriglyceridemia in the emergency department should become an easy, safe and effective option with the use of an emergency intensive care unit.     

Acute cholecystitis in the emergency department

Acute cholecystitis is a frequent consideration in patients presenting to the emergency department with the challenging complaint of upper abdominal pain. It is estimated that 20% of American adults have gallstones, and of these a large percentage (about one-third) will at some point develop acute cholecystitis. The epidemiology and associated risk factors of acute cholecystitis are briefly reviewed along with the pathogenesis and clinical presentation of the disease. Finally, an approach to the diagnosis in the emergency department and suggested management is discussed including a comparison of the strengths and weaknesses of ultrasonography and hepatobilary scintigraphy.     

Research Agenda for the Prevention of Pain and Its Impact: Report of the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy

After the 2011 Institute of Medicine report on chronic pain, the Interagency Pain Research Coordinating Committee (IPRCC) was created to enhance research efforts among federal agencies. The IPRCC and Office of Pain Policy at the National Institutes of Health collaborated to identify gaps in knowledge and address them via a Federal Pain Research Strategy (FPRS). Interdisciplinary work groups (WGs) were established to make research recommendations in 5 areas: prevention of acute and chronic pain, acute pain and acute pain management, transition from acute to chronic pain, chronic pain and chronic pain management, and disparities in pain and pain care; cross-cutting issues were also considered. The objective was to provide guidance on current research and to make recommendations about addressing identified gaps. Findings from the Prevention of Acute and Chronic Pain WG are summarized in this article. The WG created subgroups to develop recommendations on specific aspects of prevention of acute and chronic pain, including: public education, primary prevention, secondary prevention, tertiary prevention, transition from acute to chronic pain, and cross-cutting mediators. No formal literature review was conducted; however, external advisors were available and consulted as needed. Seven key research priorities were identified. The one deemed “greatest near-term value” was to optimize public health strategies to educate patients on managing pain; that deemed “most impactful” was to determine an association between patient and intervention factors. Other recommendations were related to the epidemiology of acute pain from health care procedures, the epidemiology of acute pain from work-related injuries, safety and effectiveness of management of pain associated with health care procedures, optimizing approaches to acute postsurgical pain, and safety and effectiveness of early interventions for tertiary prevention. Stakeholders, including federally sponsored research programs, researchers, health care providers, policy makers, patients, and others should work together to implement recommendations and address important gaps.

Abdominal radiograph pearls and pitfalls for the emergency department radiologist: a pictorial review

Abdominal plain films are often the first imaging examination performed on a patient with abdominal pain in the emergency department. Radiograph findings can help guide clinical management and the need for advanced imaging. A pictorial review of a range of abdominal radiograph findings is presented, including bowel gas patterns, abdominal organ evaluation, pathologic gas, calcifications, implanted devices, and foreign bodies.

     

Emergency nurses' knowledge of perceived barriers in pain management in Taiwan

Aims and objectives. To explore knowledge of and perceived barriers to pain management among emergency nurses in Taiwan. Background. Pain is the most common patient complaint in emergency departments. Quality care of these patients depends on the pain knowledge and pain management skills of emergency nurses. However, no studies have explored emergency nurses’ knowledge of and perceived barriers to pain management in Taiwan. Design and methods. Nurse subjects (n = 249) were recruited from nine hospitals chosen by stratified sampling across Taiwan. Data were collected using the Nurses’ Knowledge and Attitudes Survey‐Taiwanese version, a scale to assess perceived barriers to pain management and a background information form. Results. The overall average correct response rate for the knowledge scale was 49·2%, with a range of 4·8–89·2% for each survey question. The top barrier to managing pain was identified by these nurses as ‘the responsibility of caring for other acutely ill patients in addition to a patient with pain. Knowledge of pain management had a significant, negative relationship with perceived barriers to pain management and a significant, positive relationship with extent of clinical care experience and total hours of prior pain management education. In addition, scores for knowledge and perceived barriers differed significantly by the nursing clinical ladder. Perceived barriers also differed significantly by hospital accreditation category. Conclusions. Our results indicate an urgent need to strengthen pain education for emergency nurses in Taiwan. Relevance to clinical practice. The pain education should target knowledge deficits and barriers to changing pain management approaches for Taiwanese emergency nurses.     

Does severe acute pain provoke lasting changes in attentional and emotional mechanisms of pain-related processing? A longitudinal study

Pain experiences, learning, and genetic factors have been proposed to shape attentional and emotional processes related to pain. We aimed at investigating whether a singular major pain experience also changes cognitive-emotional processing. The influence of acute postoperative pain after cosmetic surgery of the thorax was tested in 80 preoperatively pain-free male individuals. Acute pain was measured as independent variable during the first week postsurgery by pain intensity ratings and the requested analgesic boluses (Patient-Controlled Epidural Analgesia (PCEA)). Pain catastrophizing (Pain Catastrophizing Scale (PCS)), pain anxiety (Pain Anxiety and Symptom Scale (PASS)), pain hypervigilance (Pain Vigilance and Awareness Questionnaire (PVAQ)), and attentional biases to emotionally loaded stimuli (including pain) in a dot-probe task were assessed 1 week, 3 months, and 6 months postsurgery as dependent variables. Hierarchical regression analyses were performed to test whether the 2 acute pain parameters can predict these cognitive-emotional variables. As a rigorous test, significant prediction was required in addition to the prediction of the dependent variables by themselves with lag-1. Acute pain (mainly the pain ratings) appeared to be a significant predictor for PCS, PASS, and PVAQ 1 week after surgery (deltaR² = [8.7% to 11.3%]). In contrast, the attentional biases in the dot-probe task could not be predicted by the pain ratings. The levels of pain catastrophizing and pain hypervigilance increased in the acute phase after surgery when influenced by acute pain and declined, along with pain anxiety, during the next 3 months. In conclusion, a one-time intense pain experience, such as acute postoperative pain, appeared to produce at least short-lived changes in the attentional and emotional processing of pain.