Painful to think about? Assessment and Management of Pain in the ED

Authors: Liz Herrieven, Charlotte Davies / Editor: Liz Herrieven / Codes: PC1, PC2, PC3, SLO1, SLO5 / Published: 21/02/2023

Pain is probably the most common reason for people to attend the Emergency Department (ED). It should be our bread and butter, as Emergency Physicians. Getting it right isn’t easy though. Not only are there the physical causes to unpick, but also the impact of psychological, cultural and contextual influences to trip us up. Time and again, the RCEM national audits, and more recently quality improvement projects, have shown that, when managing children in pain, emergency departments are consistently poor at assessing and treating pain, reassessing and responding to that reassessment¹.

With regards to children, some of this will be to do with our lack of confidence when assessing pain in pre-verbal or non-verbal children. It’s much easier to recognise someone is in pain when they say, “Oh doctor, this is rather painful, you know”. Some of our poor performance will also be to do with reluctance to use strong analgesics in children, for fear of causing side effects. It is true that, for those more used to managing adults, many medications are less predictable in children, who may, depending on their age and weight, have different liver or renal metabolism, have smaller fat stores or a larger body weight percentage of water, for example. But we still have a duty to manage pain appropriately, whatever the age of our patients.

Assessment of Pain

Assessing pain is more than just asking “How bad is it, on a scale of 0 to 10?”. If we’re going to do that, we need to give some examples and make it relatable for the patient. What does their pain stop them doing? Can they cope with daily activities whilst they’re in pain? Have they had to alter what they do or how they move? If their pain allows them to carry on with their daily life, but with some niggles, then it’s probably a 2 or a 3. If it’s too painful to do anything except think about the pain, it’s probably a 9 or a 10. Give them context and you’ll get a more reliable answer.

Visual scales can be really useful. Wong-Baker faces for children are commonly used, but again need to be used appropriately. The child has to understand what you want from them. They have to be able to show you which face represents how they feel when in pain. Otherwise, who wouldn’t just point at the smiley face because it looks more friendly than the crying face?

For those who cannot verbalise their pain, whether adults or children, we rely on non-verbal cues such as facial expression, activity, posture or noises. The FLACC scale is a more formal way of assessing pain using these things, particularly designed for pre-verbal children.

For some people, particularly those who are autistic or who have sensory processing challenges, pain may be expressed in different ways, specific to the individual. DisDAT (the Distress and Discomfort Assessment Tool)² is a way of trying to record this. It’s not something we’d complete in ED, but is designed to be filled in by someone who knows the person well, perhaps over time, noting behaviours or characteristics that are present when the person is in discomfort. The completed tool can then be used as a reference when the person is being assessed by someone who doesn’t know them well (such as an Emergency Physician).

The Paediatric Pain Profile³ is used in a similar way for children with severe physical impairments or learning disability. Hospital passports can also be a really useful way of finding out more about how a person might present if they are in pain⁴ and don’t forget you can always ask parents or carers. Admit they are the expert in their loved one and ask them how their child, brother, cousin, resident would usually show them they are in pain.

The Pain Pathway

Once we’ve decided someone is in pain, we then need to manage it. Pain follows a well-defined pathway, which gives us plenty of opportunity to intervene. First off, trauma, inflammation or infection triggers the local release of chemical mediators such as prostaglandins, which trigger an action potential. This is transduction. Next, the action potential travels along the nerves to the spinal cord and up to the brain. This is transmission. Signals are received by the brain – perception – and the brain attempts to start to tackle the pain by releasing endorphins and serotonin – modulation.

Management of Pain

We can start to manage pain right at the beginning of the pain pathway. Chemical mediator release, and so transduction, can be reduced by the use of splints, ice packs and elevation.

Analgesic medication and local anaesthetics work on the transmission and perception stages. Paracetamol and ibuprofen are great simple analgesics. Codeine isn’t used in children – it’s not great in adults either. It is pretty unpredictable in its metabolism (to morphine) with some getting a huge morphine hit and others nothing at all. Children with airway issues and sleep apnoea are particularly at risk. NSAIDs like diclofenac are a great middle ground though. We’ve all heard of the pain ladder and know how to work our way up it, prescribing stronger analgesia as we go, but don’t be afraid to start at the top of the ladder for someone in significant pain. That may mean morphine, diamorphine, fentanyl or ketamine, for example.

Cardiac Sounding Pain	GTN Spray or Infusion	Works in seconds but don’t use it to make a diagnosis.
Urinary retention	Catheterisation	Works immediately
Constipation	Consider enemas but rule out other causes of discomfort first.	Absorption variable
Spasmodic pain	Buscopan	Poor oral absorption, but very useful in IBS of bowel and chest.
Gynae pain	NSAIDs and warmth	Consider a hot water bottle if any available.
Sickle pain	Warmth, fluids Analgesia as per plan
Heartburn	Gaviscon	Works immediately. PPIs can take a few weeks to work, and pink ladies aren’t recommended any more.
Migraines	Aspirin + anti-emetic as per local migraine policy
Burns	Cooling for 20min in tepid water
Broken bones	Comfortable support /splints Nerve blocks
Gout	Prednisolone	On specialist advice?
Ophthalmology r/v	For glaucoma
Procedural	Entonox, Penthrox (not licenced for use in children), conscious sedation
Rib Fractures	Topical lidocaine patches SAP blocks
Dental Pain	Abscess drainage + dental blocks (if trained)
Back Pain	Consider diazepam Trigger point injections if trained.

Directed Analgesia

Think about the route you’re going to use, too. Oral medications are acceptable to most patients, although if they are vomiting then it might be best avoided. Some children (and some adults) might find swallowing medication more challenging, and don’t forget that delayed gastric emptying in trauma may make the speed of onset of medications such as oral morphine solution unpredictable or delayed.

Intranasal is great. Diamorphine, fentanyl and ketamine can all be given this way, with pretty quick onset of action. It’s acceptable to most patients, too.

Don’t forget rectal. Diclofenac PR, in particular, is an excellent analgesic for renal colic, for example.

Inhalational analgesia (Entonox – 50:50 nitrous oxide and oxygen, or Penthrox – methoxyflurane) can be a great way to get someone comfortable in a hurry, and gives them some control over their treatment. Don’t forget that nitrous oxide expands and will cause problems if given to patients with bowel obstruction, pneumothorax or pneumocephalus, for example, and Penthrox isn’t licensed for use in children. Volatile analgesics and anaesthetics aren’t a great option for the environment, either.

We often shy away from cannulating children to give pain relief – after all, cannulating children is difficult and distressing for us as well as for the children. Don’t write off intravenous analgesia completely though. The intravenous route allows for great titration and the opportunity to actually get our patient comfortable. It’s a trade-off – yes, there’s an uncomfortable procedure to get through, but then we can get rid of your pain. If you make this promise, though, don’t break it.

Remember how useful nerve blocks, local anaesthetics and topical treatments such as LAT gel⁵ can be, and use these alongside your traditional analgesia.

Step Zero	Directed Analgesia	See table above
Step One	Paracetamol	There is no evidence IV works any more effectively or quicker than PO. IV is more expensive. Don’t forget PR as an option.
Step Two	NSAIDs Ibuprofen, Diclofenac	See BNF. Always start with ibuprofen as least cardio-toxic. Evidence around bigger doses being more effective is conflicting – but anecdotally bigger doses are probably better. PR diclofenac useful in renal colic.
Step Three	Weak Opiates	Codeine should never be used for headaches, should be carefully considered in the elderly and never used in children. It should never be given as a sole agent – give with paracetamol. 60mg is not significantly more effective than 30mg but has considerable side effects. Tramadol should only be given if the patient is on it already- it’s a horrible drug. Codeine and tramadol should never be given in combination.
Step Four	Nefopam	Consider it carefully – it shouldn’t be used lightly, especially in the elderly. But works well. Not used for children.
Step Five	Strong Opiates Morphine – PO, SC, IM or IV Oxycodone Fentanyl, diamorphine	Oral is often preferable and works in about 30min. IV peaks in 20min. Oxycodone is better for adults with renal impairment. Intranasal fentanyl or diamorphine are fast-acting and can help avoid needles in children.
Step Six	Neuropathic Agents Gabapentin, amitriptyline	These take a while to work and should not be initiated in the emergency department.

Analgesic Ladder

When it comes to perception and modulation of pain, then keeping calm, being reassuring and giving clear explanations are all key. For children, distraction can be great. For adults, distraction can also be great, but might be more along the lines of chatting and putting them at ease, rather than blowing bubbles. For adolescents, let them have their social media fix. Don’t forget to also keep parents and carers calm as anxiety is truly infectious.

 

Analgesia	Provide analgesia or pain relief rather than pain killers (they’re a nocebo). Be positive in your belief of their effectiveness. Consider directed or general analgesics and don’t forget adjuncts such as LAT gel or nerve blocks.
Breathing	Square or Rectangular breathing Circular breathing – imagine breath flows up one side of their body as you breathe in, and down the other side of the body as you breathe out. Purifying breathing – imagine the body is surrounded by a pleasant light or colour. As they breathe in, imagine sending that light or colour all throughout the body. As they breathe out, they can breathe out any feelings of discomfort, tension or fear.
Comfort	Ask for a comfort score Be truthful but reassuring. Remember pain is compounded by anxiety and fear – the emotional component. Change the focus away from the pain – ask for comfort scores not pain scores, ask what they like doing when they’re not in the hospital. Avoid nocebo Saying something like: “Are you familiar with mental imagery and how it can redirect biochemical processes? Whilst we’re waiting for the treatment to work, we can enhance the healing process, and help your body respond to the treatment. I wonder if you’d like to close your eyes, and as you do, notice the immediate increase in comfort. Now, just allow that feeling of increased comfort to increase even more. As it does, notice you are beginning to relax the muscles around your abdomen a little more, and that this also increases the sense of comfort. Good.”
Distract	Change the focus from the discomfort. Provide a task. “As you lie comfortably here, plan what you’re going to do in the future when you’re comfortable”.
For more details and resources on these techniques, take a look at the “Handbook of Communication in Anaesthesia & Critical Care: A Practical Guide to Exploring the Art” by Allan Cyna et al. and consider the RCoA toolkit on preparing your mind – many transferrable skills.

The ABCD of Pain Management

Once you’ve done your best to manage your patient’s pain, don’t stop there. Reassess and respond to that reassessment. If they are still in pain, or the pain returns, you still have work to do.

Managing pain not only helps our patients – that’s probably why they’re in the ED, after all – but it can give us great job satisfaction, and that’s always worth having.

References

1. Royal College of Emergency Medicine. Pain in Children. National Quality Improvement Project. National Interim Report 2020/21. Jan 2022.
2. Distress and Discomfort Assessment Tool (DisDAT). St Oswald’s Hospice.
3. Paediatric Pain Profile (PPP).
4. Liz Herrieven, Erica Donovan and Tara McCormack . Hospital Passports, Don’t Forget the Bubbles, 2021.
5. Carley S. Please Use Less Ketamine – LAT Gel At St.Emlyn’s, 2012.