The latest guidelines for emergency analgesia evaluation and medication are very clear, and collect them quickly!

*Only for medical professionals to read and refer to the first medical experts to focus on! Patients in the emergency room often face pain symptoms, and most patients receive treatment with pain symptoms in the emergency room
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Many diseases in neurology, such as hemorrhagic stroke and subarachnoid hemorrhage, often face pain problems
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At the 7th Annual Conference of the Chinese Stroke Society (CSA&TISC 2021), Professor Guo Wei from the Emergency Department of Beijing Tiantan Hospital, Capital Medical University, brought us an interpretation of the 2020 European Association of Emergency Medicine Guidelines for Emergency and First Aid Pain
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A study on the current situation of pain in emergency patients found that pain is one of the common symptoms of emergency patients, with an incidence of more than 60%, about 20% of patients complained of moderate to severe pain, and about 70% of acute pain patients’ pain was not adequate Treatment
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Common pains in emergency patients include trauma pain, abdominal pain, chest pain, headache, arthralgia, cancer pain, etc.
, as shown in Table 1
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As early as 2001, relevant international organizations have already proposed that pain is the fifth vital sign
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Table 1: Common pain in emergency patients (organized from Professor Guo Wei's PPT) Analgesia and sedation are an important part of the treatment of emergency patients.
Comfortable analgesia for patients can bring many clinical benefits and has important clinical significance [ 1]
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Specifically include: (1) Relieve anxiety and fear, and reduce the psychological harm caused by trauma to the patient
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(2) Relieve pain and promote early functional exercise
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(3) Effectively regulate the body's stress response and reduce the body's high load state
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(4) Improve the body's repair ability and reduce the complications of important organs
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(5) Improve the quality of clinical treatment
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(6) Reduce the incidence of complications and mortality
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A series of evidence-based medical evidence shows that the early and correct use of analgesics can not only significantly reduce the pain of patients, but also does not affect the accuracy of diagnosis
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Introduction to the 2020 EUSEM Guidelines In September 2020, the European Society of Emergency Medicine (EUSEM) issued guidelines for the assessment and management of acute pain in emergency first aid[2,3].
Pain management is an important part of patient diagnosis and treatment
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The guidelines are divided into two parts: Part 1, which mainly provides guidance and recommendations for the assessment of acute pain in emergency first aid
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The second part mainly provides guidance and suggestions for emergency management of acute pain
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Assessment of acute pain in emergency first aid (1) NRS, numeric rating scales, or pain numerical evaluation scale, the European Pain Initiative (EPI) survey shows that NRS is the most used assessment tool
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NRS is easy to understand, easy to use, easy to implement, and time-consuming
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This is also the scale that Professor Guo Wei focused on introducing and recommending the use of emergency first aid
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Figure 1 shows a common NRS score in hospitals, with 0 points indicating no pain, 1-3 points for mild pain, 4-6 points for moderate pain, and 7-10 points for severe pain
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Figure 1: Numerical Pain Rating Scale (NRS) (picture from the Internet) Critical Care Pain Observation Tool (CPOT) For critically ill patients, who may not be able to communicate with them verbally, observation is needed to assess the patient's pain status
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The commonly used tool is the critical-care pain observation tool (CPOT) (Table 2).
If CPOT is greater than or equal to 2 points, it is considered that the patient has pain
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Table 2: Critical Care Pain Observation Tool (CPOT) Emergency First Aid Management of Acute Pain Non-pharmacological treatment management includes: psychological comfort; relaxation techniques, such as concentration and deep breathing, relaxation methods to reduce anxiety and pain; attention control methods, including distraction Force technology, through music, images, breathing control, infant breastfeeding and play, etc.
, have been proven effective in adults and children, and video games are becoming a potential technology; transcutaneous electrical nerve stimulation therapy; cognitive behavioral therapy; proven Acupoint pressing (pressing specific relaxation points) can relieve pain and anxiety during ambulance transportation after minor injuries; cold/freeze therapy, heat therapy
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The physiological effects of cryotherapy include relief of pain, edema, inflammation and muscle spasm, and the physiological effects of heat therapy include relief of pain and increase in blood flow and elasticity of connective tissue; traction and support
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Skeletal traction is a common method for preoperative stabilization and pain control for patients with femoral and acetabular fractures; in complex fractures, proper fixation (such as splints for wrist/arm fractures) can reduce pain and is widely recommended
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Drug management and treatment In drug management and treatment, multimodal analgesia is the combined application of opioids and non-opioids acting on different parts of the pain pathway to achieve a synergistic effect of analgesia and help optimize the outcome of acute pain treatment.
Reduce side effects and prevent chronic pain
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Before using long-acting analgesics or patient-controlled analgesia, it is recommended to give rapid intravenous injections in small doses at frequent intervals until the pain is relieved
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The specific drug management process is shown in Figure 2
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Figure 2: Emergency medicine management process (according to Professor Guo Wei's PPT).
For specific types of drugs (see Table 3 for specific drug choices), it is recommended to use acetaminophen or ibuprofen, naproxen, diclofenac, and diclofenac for mild pain.
One of celecoxib; for moderate pain, oral acetaminophen is still the first-line medication; for severe pain, consider taking acetaminophen and/or non-steroidal anti-inflammatory drugs; the first-line medication is morphine, Fentanyl, or Sufentanil
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Table 3: Drug pain management based on pain score (according to Professor Guo Wei's PPT) IV: intravenous; PO: oral; IM: muscle; IN: intranasal; INH: inhalation; SL sublingual The patient uses ketorolac IV at 0.
25 mg/kg with a maximum dose of 10 mg
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b.
COX-2 inhibition is used in some countries to relieve acute pain, but in other countries it is avoided due to the increased risk of cardiovascular events
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c.
Analgin is related to the life-threatening granular deficiency
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d.
Titrate fentanyl to the effective analgesic or maximum dose recommended by your country/institution to ensure that the naloxone antagonist is available and can be used at any time when opioids are administered
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Note 1: For each recommendation in the group, such as acetoxyphen PO 1g, acetaminophen SL 2×0.
5g, and acetaminophen IV 1g, medical staff should choose only one of them.
If analgesia is not available If sufficient, doctors should consider adding another group of drugs.
For example, if the severity of pain requires analgesic drugs, consider ibuprofen PO 400mg, and then diclofenac PO 50mg.
The drugs in the same group should not be used in combination, such as Avoid simultaneous administration of IV opioids with diclofenac and ibuprofen or morphine and fentanyl because of the risk of side effects, including respiratory depression
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Note 2: Codeine and tramadol have also shown significant interactions with other commonly prescribed drugs (such as SSRI and SNRI antidepressants)
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Tramadol has been shown to be associated with seizures and neurological disorders
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Please pay attention to the influence of CYP2D6 on the metabolism of tramadol and codeine and other prodrugs.
Patients may be unresponsive or ultra-fast metabolizers, resulting in unpredictable plasma levels.
If the patient is not clear about the status of these drugs, consider using alternatives Oral medications, such as morphine
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Opioids Introduction Opioids are the first-line drugs for the treatment of severe pain.
However, due to concerns about addiction and other reasons, when opioids are needed to treat pain, they are often not effectively used
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Mastering the principles and methods of use of opioids will help the rational use of opioids in pain management
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Opioids include morphine, fentanyl, sufentanil, hydromorphone and so on
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Morphine is contraindicated in patients with unstable hemodynamics
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Fentanyl has a sustained analgesic effect and a strong analgesic effect
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Sufentanil also has the characteristics of continuous analgesia and strong effect
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Hydromorphone is a semi-synthetic derivative of morphine, which has a strong effect on central mu opioid receptors and is suitable for the treatment of moderate to severe pain
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The advantages of hydromorphone include quick onset (Table 4), good analgesic effect, and low side effects (Figure 3), and it can be used for special populations (elderly patients, children patients)
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There are currently two dosage forms: ampoules can be administered by intravenous, subcutaneous, intramuscular, epidural, etc.
, with the characteristics of diluting, adjustable concentration, and more flexible medication; pre-filled dosage forms can be administered subcutaneously or intramuscularly , Single medication for one person, has the characteristics of saving configuration, easy operation and rapid administration, eliminating the need for the transfer of liquid medicine from the glass package to the syringe, and reducing the waste of medicine due to adsorption
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Table 4: Some pharmacokinetic parameters of oxymorphone (according to Professor Guo Wei's PPT) Figure 3: Hydromorphone has fewer side effects compared with morphine (picture from Professor Guo Wei's PPT) Outlook despite the 2020 version of the European emergency department for acute pain The evaluation and management guidelines of the company have been launched for nearly a year.
The attention of emergency medical staff in China on analgesia and sedation has increased to a certain extent, but the awareness and practical ability of treatment indications, evaluation methods, drug selection, etc.
need to be further Improving, promoting and standardizing analgesia and sedation strategies is one of the important tasks of the emergency department in China in the future
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Reference materials: [1] Xu Shiheng, Hu Peiyang.
Research progress in early analgesia management of trauma patients[J].
Chinese Health Emergency Electronic Journal,2017,3(2):122-124.
[2]Hachimi-Idrissi S,Coffey F ,Hautz WE,et al.
Approaching acute pain in emergency settings:European Society for Emergency Medicine(EUSEM)guidelines-part 1:assessment.
Intern Emerg Med.
2020;15(7):1125-1139.
[3]Hachimi-Idrissi S, Dobias V, Hautz WE, et al.
Approaching acute pain in emergency settings; European Society for Emergency Medicine(EUSEM) guidelines-part 2: management and recommendations.
Intern Emerg Med.
2020;15(7):1141-1155.