ED Assessment and Treatment of Patient’s Pain
Search Strategy: You search PUBMED using Clinical Queries under narrow search parameters for “acute pain” and “Emergency Department” and “Visual Analog Scale”. The articles selected from the list of 88 citations that looked at clinical vs. statistical significance, correlation between visual and verbal pain scales, patient satisfaction correlating with changes in pain scores, and morphine dosing used to control pain.
A 48 year old post menopausal female presents to your ED complaining of abdominal pain and left flank pain unresponsive to ibuprofen and acetaminophen at home. She states the pain is similar to the last time she had a kidney stone. Her past medical history also includes hypertension. The patient complains of left lower quadrant tenderness and left flank pain that comes and goes in waves of cramping sharp stabbing pain. The remainder of her physical exam is unremarkable. She currently is vomiting non bilious emesis and appears to be in moderate distress from her pain and vomiting.
The nurse reports normal vital signs except for tachycardia with a pulse of 110. The triage nurse reports her pain self-rating at 9 of 10. The nurse is now relaying to you that the patient is pleading for relief of her pain and nausea. The patient offers that Demerol usually works for her when she has this type of pain and she has no medication allergies. A urine dip is positive for blood. The patient weighs 80 kg (176 lbs).
Because of a high adverse event profile, your emergency department no longer uses Demerol (meperidine). Instead, Morphine is available in the pyxis. You usually order 2 or 4mg doses of IV morphine for all patients regardless of weight, but really don’t know why you do except that most others seem to write for these doses and patients seem to get some relief. You wonder what the most appropriate starting dose of morphine would be based on previously studies looking at patients presenting with acute undifferentiated painful conditions. Furthermore, you wonder about the usefulness of the verbal and visual analog pain scales used frequently in the emergency department. You also question how changes in these ratings correlate with patient satisfaction and pain relief.
Population: ED patients presenting with undifferentiated painful conditions
Intervention: Pain medication use, specifically morphine use
Comparison: Differences in dosing of morphine
Outcome: Clinical significance of changes in different pain scores
First years: Prospective Validation of Clinically Important Changes in Pain Severity Measured on a Visual Analog Scale. Ann Emerg Med. 2001; 38: 633-638. *PGY-1 also see (reference article for above study frequently mentioned) Clinical Significance of Reported Changes in Pain Severity. Ann Emerg Med. 1996; 27: 485-489.
Second years: Validation of a Verbally Administered Numerical Rating Scale of Acute Pain for Use in the Emergency Department. Acad Emerg Med. 2003; 10: 390-392.
Third years: Patient Expectations for Pain Medication Delivery. Am J Emerg Med. 2001; 19: 399-402.
Fourth years: Randomized Double-Blind Placebo-Controlled Trial of Two Intravenous Morphine Dosages (0.10 mg/kg and 0.15 mg/kg) in Emergency Department Patients With Moderate to Severe Acute Pain. Ann Emerg Med. 2007; 49: 445-453.
Article 1: Prospective Validation of Clinically Important Changes in Pain Severity Measured on a Visual Analog Scale, Annals of EM 2001: 633-638
Article 2: Validity of a Verbally Administered Numerical Rating Scale of Acute Pain for Use in the Emergency Department, Acad EM2003;10: 390-392
Article 3: Patient Expectations for Pain Medication Delivery, Am J EM 2001;19: 399-402
Article 4: Randomized Double-Blind Placebo-Controlled Trial of Two IV Morphine Doses in ED Pts with Moderate to Severe Acute Pain, Ann EM 2007;49:445-453
ED patients presenting with pain-related complaints expect analgesia within 23-minutes, but actually receive it at a mean of 78-minutes. The minimum change on the visual analog scale (VAS) indicating any improvement in the patient’s pain is 13 mm and for the (one to ten) numeric pain rating scale that we use 1.3. No difference exists between 0.1mg/kg and 0.15 mg/kg (in two-doses) Morphine for 60-minute pain-relief, although Morphine is frequently underdosed anyway and one barrier to Knowledge Translation may be nursing reluctance to administer even 0.1mg/kg morphine. Future research should assess VAS and numeric pain rating scales against Gold-standards with better content and construct validity than simple patient report. One idea might be a composite score incorporating subjective pain ratings, objective pain assessments by impartial observers (family, nursing, and/or clinician), analgesic requirements, functional disability, and perhaps even PET scanning to identify cultural/gender differences in the subjective experience of pain. Additionally, Knowledge Translation barriers to effective, efficient pain-relief in EM should be identified and overcome.