Journal of Emergencies, Trauma, and Shock
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Year : 2017  |  Volume : 10  |  Issue : 4  |  Page : 167-168
What's new in emergencies trauma and shock - Adequate pain management in the emergency department - A dream come true!

Department of Anaesthesiology and Emergency Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Click here for correspondence address and email

Date of Submission10-Jun-2017
Date of Acceptance13-Jun-2017
Date of Web Publication12-Oct-2017

How to cite this article:
Sahu S. What's new in emergencies trauma and shock - Adequate pain management in the emergency department - A dream come true!. J Emerg Trauma Shock 2017;10:167-8

How to cite this URL:
Sahu S. What's new in emergencies trauma and shock - Adequate pain management in the emergency department - A dream come true!. J Emerg Trauma Shock [serial online] 2017 [cited 2022 Sep 25];10:167-8. Available from:

“Pain is, with very few, if indeed any exceptions, morally and physically a mighty and unqualified evil. And, surely, any means by which its abolition could possibly be accomplished, with security and safety, deserves to be joyfully and gratefully welcomed by medical science”, Sir James Young Simpson, administered of the first obstetrical anesthesia.[1]

The environment and management inside operation room and Intensive Care Unit setting of acute pain management is entirely different from emergency department (ED). It can be a single most symptom and cause of maximum number of the patient presented because of various diseases to the ED. Addressing pain can be the most important rewarding to the ED Physician. Pain management should be prime target during optimization of a patient's care in ED. This is making the pain as 5th vital sign to be monitored in ED. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated as said by James Campbell in presidential address of American Pain Society.[2]

The term “ED oligoanalgesia” was coined in 1989 raises the level of attention of inadequate pain care in acute care settings. The thought “treat the patient as if they were your family member” is most suitable to direct and guide physician in ED.[3] Spectrum of treatment from Oligoanalgesia (phenomenon of undertreatment of pain) to multimodal analgesia in ED (uses more than one method of pain management) was a long journey that took years even in developed world. Multiple methods can actually reduce the amount of medications necessary to relieve pain and can minimize uncomfortable side effects. Now to era of prehospital analgesia (administration of analgesia to trauma patients in prehospital settings), the term of success story of pain management in acute emergency and trauma settings. With the availability of various opioid, nonopioid and synthetic opioid large numbers of shorter and intermediate acting potent drugs in the armamentarium with are safer in emergency and trauma situation. Nowadays, analgesics dosages, times of onset, duration, and other pharmacologic information are quickly and easily available from a various online sources as a ready reference.[4] Pain relief is now being quality indicator in ED used as a basis for both internal and external judgement and evaluation to know as to how well one ED is doing.[5]

The ED is the busy and tense environment. The procedure done in ED during resuscitation and stabilization may be painful in itself. The pain caused by the ED workup and stabilization should be taken into account when analgesia care is considered. If pain is too much, it can create barriers to obtaining an adequate history and physical examination from patient. If one overcome these barriers by adequate and faster pain relief may facilitate better patient care. Pain assessment has been underemphasized in actual clinical practice. Besides simple tool such as Numerical Rating Scale, visual analog scale to brief pain inventory, medical interview satisfaction scale or complex assessment in children, or altered mental status. In most acute care patients, a simple “zero-to-10 scale” or 100 paisa scales in developing country are simple or most acceptably reliable tools.[6] The risks and side effects of different analgesics treatment such as hypotension, hypoxemia, respiratory depression and other organ dysfunctions should be considered. However, on weighing the risk/benefit ratio, making the patients more comfortable is must. In addition of improving patient comfort, relief of pain have more physiologic advantages in emergent situation such as acute coronary syndrome, various neurological disorders with raised intracranial pressure, trauma settings, obstetric, and pediatric patients.

Regarding drug prescription in ED, it is worth pointing out that if a particular drug has not been tried before the admission, it may work like over-the-counter, nonopioid drugs. Opioids analgesics are potent, increases side effects, and abuse potential to drug seekers. In ED, the right initial approach may even with a “generalized pain medication” such as an nonsteroidal anti-inflammatory drug or opioid. When drug abuse is not an issue, addition of ultrasonography-guided regional blocks as part of multimodal approach can be ideal approaches to pain management in the ED as targeted analgesia.[4] The key with regard to analgesic administration route always use intravenous for immediate, predictable effect as other routes used in nonemergent conditions delay absorption, and timely action. Pain management is an ongoing process start from prehospital, in hospital, and continue till the discharge hospital. It is usually said pain is easier to prevent than treat, especially important in unscheduled return ED visits of patients, who denied warranted analgesia due to various causes and addiction.[7]

ED physicians would be more wiser if in addition to stabilization and life-saving therapy, prioritizing patient's pain and comfort as better end-point. Recent review of literature of various studies pointed out ethical concerns, barriers, risk/benefit, and methods to overcome all these issues. One of the study published in this issue of journal highlighted the effect of implementing a protocol-based pain management in the ED of developing country and its effect on time to analgesia and adequacy of analgesia obtained. They showed that introduction and implementation of pain management protocol in ED reduces mean time to administer analgesic with significant difference in pain relief achieved with better patients' satisfaction score.[8]

One can change the direction of pain and sufferings in ED tremendously. Enough well-proven literature, guidelines and protocols are available. Only need is feeling other pain like own and manage it as we need the remedy, in any corner of the world.

   References Top

Simpson J. Anesthesia. In: Simpson W, editor. The Works of Sir J. Y. Simpson. Edinburgh, UK: Adam and Charles Black; 1871.  Back to cited text no. 1
Thomas S, editor. Emergency Department Analgesia: An Evidence-Based Guide. 1st ed. Cambridge, UK: Cambridge University Press; 2008.  Back to cited text no. 2
Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med 1989;7:620-3.  Back to cited text no. 3
Maddock A, Ferris J. Prehospital analgesia. Br J Anaesth 2013;110:848.  Back to cited text no. 4
Wakai A, O'Sullivan R, Staunton P, Walsh C, Hickey F, Plunkett PK. Development of key performance indicators for emergency departments in Ireland using an electronic modified-Delphi consensus approach. Eur J Emerg Med 2013;20:109-14.  Back to cited text no. 5
Downey LV, Zun LS. Pain management in the emergency department and its relationship to patient satisfaction. J Emerg Trauma Shock 2010;3:326-30.  Back to cited text no. 6
[PUBMED]  [Full text]  
Wilkins PS, Beckett MW. Audit of unexpected return visits to an accident and emergency department. Arch Emerg Med 1992;9:352-6.  Back to cited text no. 7
Thomas SH. Management of pain in the emergency department. ISRN Emerg Med 2013;1:19.  Back to cited text no. 8

Correspondence Address:
Sandeep Sahu
Department of Anaesthesiology and Emergency Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JETS.JETS_64_17

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