Pain and pain management

Stratford Upon Avon First Aid 1

Pain Management


Pain and Pain Management

• Pain is the most common symptom causing patients to seek medical attention yet most formal training is primarily concerned with treating injuries and illness with hardly any time spent on how to manage the pain itself.



• In many instances correct treatment of the injury or illness will reduce pain as a consequence; cooling a burn, stabilising a joint injury or correctly positioning a casualty with chest pain, for example, will in effect reduce pain as well as correcting the cause for concern.



• Sometime this is not enough, sometimes the cause is obvious but sometimes the casualty just presents with ‘pain’. No apparent injury, no history of illness. How do you treat that?

• Sometimes, even after initial treatment, the casualty is still in pain. Definitive care is over 12 hours away. What do we do then?



• Pain in itself is not life threatening but pain can cause physiological changes in blood pressure, breathing and pulse. This is interesting but the main reason that I want to manage a casualty’s pain, is for compliance:

• A pain-free casualty will be • more compliant



• more willing to engage in their own treatment

• less dependent on others• easier to move and transport• more willing to accept potentially painful

procedures such as examination or wound cleaning, for example.



• Better rested with less disturbed sleep, less stressed and generally a nicer person to be around. This is especially important in remote areas when living in small groups or teams and in confined areas!


What is Pain?

• Pain has two primary etiologies: nociceptive and neuropathic. The difference is whether the pain stimulus comes from a nerve receptor, intended to sense pain, touch, temperature, or pressure (nociceptive); or if the pain stimulus comes directly from injury to the nerve itself (neuropathic).


What is Pain?

• Nociceptive pain, for example, is the pain that occurs when you hit your thumb with a hammer. The impact stimulates the nerve receptors, sending pain signals to the brain. If you push on the area of pain, it will make the pain worse.


What is Pain?

• Neuropathic pain, on the other hand, is radiating pain that occurs when a nerve itself is injured. For example, the casualty may have ruptured a disk in their lower back, and that disk is now compressing the left L5 nerve root of the sciatic nerve. As a result, they will have pain that radiates down the back of their leg to their foot.


What is Pain?

• When you push on the areas of apparent pain – the foot - it does not cause more discomfort because the problem is at the disc, not where the pain is presenting.


What is Pain?

• Nociceptive pain is easily managed with non-steroidal anti-inflammatory drugs (NSAIDs),paracetamol (acetaminophen in the US) and opioids. Neuropathic pain does not respond to these usual pain relievers, making it much harder to control.


Assessing Pain

• Pain is incredibly subjective and the term ‘pain’ is wildly vague. For the casualty to say “I’m in immense pain!” tells me nothing other than something is not normal. A critical, structured approach can help gather more detailed and relevant information:

PQRST


Provocation

• What caused the pain? • Does anything aggravate the pain?


Quality

• Can you describe the pain? Is it a dull ache, a sharp stabbing pain, a vice-like gripping pain or a numb tingly pain, for example?


Radiates or Refers

• Some pain radiatesoutwards; is the pain spreading? Neuropathic pain will ‘refer’ i.e. the pain is felt elsewhere. A common example is the pain felt in the tip of the left shoulder pain which can be indicative of an ectopic pregnancy. This would be worth considering if the casualty was a sexually active female of child-bearing age. Less so if your casualty is male.


Severity

• Because pain is so subjective, to describe the intensity is practically worthless; a paper-cut can be agony to one person or a mild annoyance to another. A more representative assessment would be to ask the casualty to score the pain out of 10 (10 being the worst possible pain). This again is a worthless value on its own as it is simply one person’s opinion.


Severity (Continued)

• However, if this question is repeated a change in the value stated will indicate an increase or decrease in pain. This is particularly useful if dealing with casualty’s for an extended period of time, after treating an injury or after administering pain relief.


Time

• When did it start? • Is it constant or does it come and go?


Assessing Pain

• The answers you get may enable you to make an informed decision or they may not mean anything to you.

• They will mean something to someone so whether you understand the answers or not, all communication is documented and handed over to definitive care.


Mechanisms of Pain Control

• There are several methods we can employ to help reduce pain:

• Non-medicated pain control:– Minimize and control swelling of the tissues

by RICE– Additional techniques

• Medicated pain control:– Analgesics– Specific medications


Non-Medicated Pain Control

• Pain can be reduced, to some degree, without the need of medications. The most effective and widely used techniques is the application of RICE

• Rest: Rest or completely immobilise the injured area to minimize movement.



• Ice: Apply cool compresses to the affected area to cause vasoconstriction, reducing swelling and thus reducing pain. This also minimizes any further bleeding into the damaged tissue. Ice is a metaphor for cool – NEVER apply ice directly to skin.



• If you have ice available (from a drinks bucket, a bag of frozen peas or even snow or ice itself), wrap the ice in something wet which will conduct heat quickly but will reduce the chance tissue damage.



• A regime of a maximum of 15 minutes cooling in every hour is used to ensure vasoconstriction does not lead to frostbite in the effected limb and, furthermore, alternate cooling and rewarming is more effective than continual cooling as the affected area also needs a good supply of blood to remove waste products and promote healing.



• Comfortable position: Historically the “C” has always stood for Compression but there are inherent risks in applying compression dressing to a swollen injury or injury which may continue to swell.



• This is largely academic as the casualty will probably not allow you to apply a compression dressing, in which case allowing them to adopt the most comfortable position is far more beneficial in terms of reducing pain and promoting recovery. Don’t worry about whether they should be in a high arms sling or a low arm sling – bind as you find!



• Elevation: Elevate the injured area above the level of the heart. This lowers the blood pressure and decreases the rate that blood leaks into the damaged tissue and further reduces swelling.

• Addition techniques• In addition to RICE, pain may also be

managed by:



• Positioning – There are many recognised positions for a casualty which are said to reduce pain or promote recovery with exciting names such as Trendellenberg and Reversed Recumbent. The casualty will adopt their own position. Most people with abdominal pain will bring their knees up and curl up in the foetal position.



• Casualties suffering with chest pain or breathing conditions will prefer NOT to lie down, so don’t make them. Support the casualty in the position they adopt.



• Reassurance – Pain is a physiological response to either the stimulus of nerve receptors or the presence of chemical mediators but the perception of pain can be exacerbated or suppressed depending on the level of emotional support provided to the casualty. Do not underestimate the value of emotional support.



• Distraction – By the same token, do not do everything for the casualty. The best way to make someone feel helpless is to treat them as though they are. Engaging the casualty in their own treatment and keeping them occupied is an effective method of distraction.

• Traction can relieve pain but training is essential.


Medicated Pain Control

• There is a lot if myths which are still promulgated in society in general and on some formal training courses:

• It is not illegal to give an adult a simple pain relief such as aspirin or paracetamol as long as it is done correctly. It is not illegal to give a child medication as long as it is both done correctly and there is parental consent.


• To leave tablets in front of a casualty and say "I'm just going to leave the room, if you choose to take some I won't say a word, nudge nudge wink wink“

• DOES NOT ABSOLVE YOU OF RESPONSIBILITY.


• Many people think that because we cannot give pain killers to casualties, if we suggest they take them themselves there is no harm done. THIS APPROACH MAKES YOU NEGLIGENT.


• If the casualty is in pain, you have asked appropriate questions, you know there are no known allergies and they have taken the medication before, you know what dose to give them and how often, do so and write it down.


• To leave a casualty, who clearly wants pain relief alone with medication YOU have presented to them which they otherwise would not have taken - of course they are going to take it but this time nothing is documented or observed.


• People arrive at A&E complaining of acute pain. When asked by the Triage Nurse "Have you taken any pain relief?" they frequently reply with "No, we didn't want to mask the pain." Take pain relief, that is what it is for. Commonly available over-the-counter pain relief will not mask acute pain, it will take the edge of and make things a little more bearable.


• We have probably all seen or taken aspirin, paracetamol (acetaminophen in the US) or ibuprofen at one time, or another, being the most widely available pain killers. What is important is to understand is that they are not the same:


Aspirin

• Aspirin• A mild analgesia that is known for its

additional quality of ‘thinning the blood’. It doesn’t actually thin the blood but it is what’s known as a platelet aggregation inhibitor; it inhibits blood clotting. This can be used to good effect as prophylactic medication at altitude or for these with cardiac problems.


Aspirin

• Aspirin is also given immediately after a heart attack to reduce the chance subsequent heart attacks and reduce the damage to cardiac muscle 1,2.

• 300mg – 600mg every 6 hours to a maximum of 4g a day. Take with food and avoid if there is a history of stomach ulcers or an allergy to ibuprofen or naproxen.


Paracetamol

• A much underrated pain relief; paracetamol is an effective pain killer to the extent that IVparacetamol is regularly used in A&E departments where lay-people would commonly expect much ‘stronger’ pain relief to be used.


Paracetamol

• The interesting fact about paracetamol is that it is known to work but no really understands how, just that it does! Paracetamol has additional properties in reducing fever although paracetamol should not be given to reduce a fever unless it is over 40oc – the root cause of the fever needs to be addressed.


Paracetamol

• Paracetamol – like all drugs – does not come without warning. Paracetamol is toxic in comparatively small amounts.

• 500mg – 1g (one to two tablets) every 4-6 hours to a maximum of 4g a day. Paracetamolshould be avoided where there is a history of liver problems


Ibuprofen

• Ibuprofen (or ‘brufen’) is well known as an anti-inflammatory and therefore ideal for bone or joint injuries however as platelet aggregation inhibitor (although to a far lesser degree thanaspirin) it should be avoided in the first two days of injury as it may promote bleeding into the tissue, in which case start with paracetamol and add ibuprofen if needed.


Ibuprofen

• 200mg-400mg 8 hourly – with food – to a maximum of 1200mg a day.


Naproxen

• Naproxen is, like ibuprofen, an effective anti-inflammatory but is better tolerated with less stomach irritation. Naproxen is not available over-the-counter in its standard form but is available under the trade name Feminax UltraTM.

• 500mg first followed by 250mg 6-8 hours later. 250mg 8 hourly on the 2nd and 3rd day.


Paracetamol + Ibuprofen

• Both ibuprofen and naproxen can be combined safely to increase the efficacy to greater effect than some narcotics. Interestingly the addition of paracetamol increases the analgesic effect of both regardless of the doses of either ibuprofen or naloxone – higher doses of either in combination with paracetamol is not proven to increase analgesic effect.


Paracetamol + Ibuprofen

• 400mg ibuprofen 8 hourly (to a maximum of 1200mg in 24hrs) + 1g paracetamol 6 hourly (to a maximum of 4mg in 24 hours)


Codeine

• Both ibuprofen and paracetamol are currently available with codeine over-the-counter. These represent the strongest openly available analgesics.

• Codeine has a constipative effect so your casualty may need to consider laxatives if on codeine for several doses.


Antihistamines

• Clorpheniramine (PiritonTM) is primarily used as an antihistamine for the treatment of mild allergic reactions including hay fever but also has a mild sedating and analgesic effect.


Antihistamines

• In a remote setting, whilst not licensed for the treatment of anaphylaxis, chlorpheniramine may be of benefit from some exhibiting a severe reaction.


Antibiotic Creams

• Pain relief will only mask the symptoms of eye, ear or skin infections so treat the infection itself.


Indigestion

• If normal antacids (Gaviscon or Rennie, e.g.) are not effective, ranitidine can be used. Read the label.


Sore Throat

• Typical pastels have no medicine effect other than activating saliva and tasting sweet. Dequacaine contains a mild anaesthetic for the most painful of sore throats but again, it treats the symptoms, not the cause which must also be addressed.

Health & Medicine

Pain and pain management