1EMCON 3, 29th December 2010 to 1st January 2011, Dhaka,

Bangladesh

““I will I will rememberremember that I do not treat a fever chart, a that I do not treat a fever chart, a cancerous growth, but a sick human being.”cancerous growth, but a sick human being.”

Dr Mohammed Ohidul AlamDr Mohammed Ohidul AlamFCPS FRCSI FRCSEd MRCSEd(A&E) FCEM(London)FCPS FRCSI FRCSEd MRCSEd(A&E) FCEM(London)

Consultant Emergency MedicineConsultant Emergency Medicine

Conquest HospitalConquest Hospital

United KingdomUnited Kingdom

Do children get Pain ?

Do elderly get pain?

Yes, They do!!!!!

A-fiber 10-20m/secC-fiber 1 m/sec 2

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh3

CEM standards for analgesia are for Severe pain Moderate pain

in 20 mins 50%in 30 mins 75% 75%in 60 mins 98% 90%

Definition: The term pain is a subjective experience that typically accompanies nociception.

Why pain is a priority?◦ Pain is a very unpleasant, sensation to all human beings

and therefore control of pain in the ED is a priority’

◦ Short and long term effect of pain Potential deterioration Systemic effects on body Acute psychosis & chronic post-traumatic stress disorder

• Few facts to consider• Commonest presenting symptom is pain. 60%• Pain is commonly under recognized.• Commonly under-treated and even treated late .

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.4

When a patient in pain enters the ED he or she has two main concerns (not necessarily in this order):

◦ 1. How quickly can I get relief from my pain?◦ 2. What is causing this pain?

The major concern of professionals are:◦      1. What is the diagnosis? ◦      2. What is the treatment for the underlying

disease process?

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh 5

Triage ◦Pain score recording

◦Recording vital signs

◦To get Idea of potential problem

◦Priority to be seen by doctor

◦Giving pain relief if necessary.

6

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.

7

Pain pathway: The main pathway ascends through the dorsal horn of the spinal cord, crosses the midline to the opposite side of the spinal cord, and reaches the brain’s thalamus through the anterolateral white matter. From the thalamus, the signal is transmitted through the third order neuron to the somatosensory cortex.

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.

8

How to measure Pain score ?

9

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh

Analgesics: By definition any drug which alleviates pain without loss of consciousness is called an analgesic.

•Assess pain severityAssess pain severity•Administer analgesia Administer analgesia within 20 minuteswithin 20 minutes

Mild pain (1-3)Mild pain (1-3)Oral/rectal paracetamol Oral/rectal paracetamol 20mg/kg loading dose, 20mg/kg loading dose,

then then 15mg/kg 4-6 hourly15mg/kg 4-6 hourly

Or Or ibuprofen 10mg/kg 6-8 hourlyibuprofen 10mg/kg 6-8 hourly

Moderate pain (4-6)Moderate pain (4-6)Oral/rectal diclofenac 1 mg/kg Oral/rectal diclofenac 1 mg/kg

8 hourly8 hourly(unless already had ibuprofen)(unless already had ibuprofen)

And/orAnd/orOral codeine phosphate 1mg/kg Oral codeine phosphate 1mg/kg

4-6 hourly4-6 hourly

Severe pain (7-10)Severe pain (7-10)Consider entonoxConsider entonox

as holding measureas holding measureThenThen

Intranasal diamorphine Intranasal diamorphine 0.2 mls (0.1 mg/kg0.2 mls (0.1 mg/kg

followed by/or followed by/or IV morphine 0.1-0.2 mg/kg IV morphine 0.1-0.2 mg/kg

supplemented by oral analgesicsupplemented by oral analgesic

10

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh. 11

Agent Lipid Solubility

Potency Protein Binding

PKA Onset (mins)

Duration (mins)

Lignocaine (lidocaine)

Medium

Low

Medium

7.7

5

60-120 (100)

Bupivacaine

High

High

High

8.1

10

180-600 (200)

Prilocaine

Medium

Low

Medium

7.7

5

90-180 (120)

. 12

Agent Lipid Solubility

Potency Protein Binding

PKA Onset (mins)

Duration (mins)

Lignocaine (lidocaine)

Medium

Low

Medium

7.7

5

60-120 (100)

Bupivacaine

High

High

High

8.1

10

180-600 (200)

Prilocaine

Medium

Low

Medium

7.7

5

90-180 (120)

Fracture NOF Audit 2009 by CEM 5,543 #NOF cases from 113 emergency

departments (ED) were included in the 2008 audit.

Nationally, 10% of audited patients received adequate

pain relief before arrival, 22% within 20minutes of arrival, 30% within 30 minutes and 52% within 60 minutes of arrival in A&E.

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.

.13

Paediatric Pain Audit 2009 by CEM 5,543 cases from 117 emergency departments

were included in the 2008 audit

Nationally,

42% of audited children receivedpain relief within 20 minutes of arrival,

55%within 30 minutes and

69% within 60 minutes of arrival in ED.

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.

.14

Murice et all EMJ 2001, Current Practice in Paediatric Analgesia, part 1

◦ Southal, 181 Invasive procedure, ◦ 28% adequate analgesia◦ Schechter 90 adult/90 children◦ ½ number doses of analgesic ◦ Friedland, 99 Children, ◦ 53% Rx adequate analgesic◦ Children < 2yrs age less likely to have analgesics

2nd International Conference on Emergeny Medicine in Dhaka,

1st to 3rd january 2010. 15

Intranasal Diamorphine Vs IM Morphine Wilson & Kendall, EMJ 1997,

◦ Safety & Efficacy of Paediatric Intranasal Diamorphine vs. IM Morphine: ◦ Total Children 58, complete data 51(88 %)

Jason & Kendall, BMJ 2001,

Multi centre trial, RCSEn’g, Bristol Children H & UCL London

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh16

Total: 404 children, Age 3-16 Yrs,

204, given Intranasal Diamorphine200 given IM Morphine

No Discomfort 95% Vs &71%

Acceptability 98% Vs 32%

Side effects Similar

Intra Nasal Diamorphine: Advantages◦ Easy Administration ◦ Quick onset of effect

◦ Good Bioavailability

◦ Very Effective pain control

◦ Can be top up easily

17EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh

• Opiates•Morphine (0.1mg/kg)•Intranasal diamorphine ( 0.1mg/kg)• Well tolerated• Onset 5 min, max effect at 1 hr• Duration 4 hours• Similar side effect like IM Morphine

18EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh

Other Analgesics◦ Entonox (NO2 50% & O2 50%)◦ Fentanyl◦ Midaziolam Oral 0.500mg/kg & no >15mg

Local anaesthetic:◦ Injections, Spray or Cream◦ Lidocaine, Amithocaine, Prilocaine

Sedation by: Ketamine Non Pharmacological propofol

19EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.

20EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.

In Summary:

1.Pain control is of priority in ED

2.Triage nurse to determine the pain score

3. Choosing right drug for right patient

4. Delivering the drug in right route

5. Often combination of drugs required

6. Initiating initial treatment immediately and

7. Facilitating definite care sooner.

EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.21

22EMCON 3, 29th December 2010 to 1st January 2011, Dhaka, Bangladesh.

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‘Lets be a trustworthy friend to our patients by making the in-hospital stay as comfortable as possible, so that we can remembered in a sweeter way for ever’.