Pathophysiology of acute pain: implications for clinical management

A Randomised Control Trial Comparing the Efficacy of Tramadol and Paracetamol against Ketorolac and Paracetamol in the Management of Musculoskeletal Pain in the Emergency Department

Background

This study aimed to compare the efficacy, acceptance and side effects of intramuscular tramadol and ketorolac in combination with oral paracetamol in the emergency setting.

Materials and methods

This was a randomised, double blind controlled trial. Patients aged 18 years or above with moderate to severe musculoskeletal pain were recruited. Patients with known allergy, currently on psychiatric medication, with alcohol or opioid dependence, during pregnancy and with major systemic illness were excluded. Tramadol 100 mg or ketorolac 30 mg was given intramuscularly together with paracetamol 500 mg per oral. They were then bed rested in the observation ward for one hour. Visual analogue scale (VAS), satisfaction score, vital signs and side effects were recorded.

Results

Altogether, 78 (M: 43, F: 35) subjects were recruited from June to September 2005, with equal number in each arm. The mean age was 39.9 for the tramadol group and 43.9 for the ketorolac group. Most of them suffered from back pain (66.7%). There was a significant difference in VAS improvement between the two groups (0.88; P=0.01). However, there were no significant differences in patients' satisfaction score and admission rate. The incidence of side effects was similar between the two groups (tramadol 19, ketorolac 17), mainly dry mouth, and none were major. The tramadol group had more nausea.

Conclusion

The analgesic effect of the tramadol and paracetamol combination is as effective as the ketorolac and paracetamol combination. Tramadol is well tolerated and relatively safe. It is also cheaper than ketorolac. Hence, we recommend tramadol and paracetamol combination for acute moderate to severe musculoskeletal pain in the emergency setting.

A simplified way for the urgent treatment of somatic pain in patients admitted to the emergency room: the SUPER algorithm

Somatic pain is one of the most frequent symptoms reported by patients presenting to the emergency department (ED), but, in spite of this, it is very often underestimated and under-treated. Moreover, pain-killers prescriptions are usually related to the medical examination, leading to a delay in its administration, thus worsening the patient's quality of life. With our study, we want to define and validate a systematic and homogeneous approach to analgesic drugs administration, testing a new therapeutic algorithm in terms of earliness, safety, and efficacy. 442 consecutive patients who accessed our ED for any kind of somatic pain were enrolled, and then randomly divided into two groups: group A follow the normal process of access to pain-control drugs, and group B follow our SUPER algorithm for early administration of drugs to relieve pain directly from triage. We excluded from the study, patients with abdominal pain referred to the surgeon, patients with headache, recent history of trauma, history of drug allergies, and life-threatening conditions or lack of cooperation. Drugs used in the study were those available in our ED, such as paracetamol, paracetamol/codeine, ketorolac-tromethamine, and tramadol-hydrochloride. Pain level, risk factors, indication, and contraindication of each drug were taken into account in our SUPER algorithm for a rapid and safe administration of it. The Verbal Numeric Scale (VNS) and the Visual Analog Scale (VAS) were used to verify the patient's health and perception of it. Only 59 patient from group A (27.1 %) received analgesic therapy (at the time of the medical examination) compared to 181 patients (100 %) of group B (p < 0.001). Group B patients, received analgesic therapy 76 min before group A subjects (p < 0.01), resulting in a significant lower VNS (7.31 ± 1.68 vs 4.75 ± 2.3; p < 0.001), and a superior VAS after discharge (54.43 ± 22.16 vs 61.30 ± 19.13; p < 0.001) compared to group A subjects. No significant differences concerning side effects were observed between group A and group B patients. Early administration of a pain-control therapy directly from triage is safe and effective, and significantly improves patients perceptions of their own health.

Use of morphine sulphate by South African paramedics for prehospital pain management

BACKGROUND

Evidence in the literature highlights the fact that acute pain in the prehospital setting remains poorly managed. Morphine remains the most commonly used analgesic agent in the South African prehospital emergency care setting. Although guidelines and protocols relating to the dosage and administration of morphine exist, little data are available describing its use by South African paramedics.

OBJECTIVES

To document and describe the way in which morphine is administered by a sample of South African paramedics for the management of acute pain in the prehospital setting.

METHODS

An Internet-based survey was conducted. Sixty South African paramedics responded by completing the online questionnaire documenting and describing their use of morphine for management of acute pain.

RESULTS

Results revealed that participants appeared to be overly cautious of potential adverse effects associated with administration of morphine. Although the majority of participants calculated the dose of morphine to be administered correctly according to the patient's weight, the majority do not appear to be administering this as a bolus; rather, they administer the calculated loading dose in a titrated manner over time. This method may result in a delay and or failure to adequately achieve therapeutic serum levels.

CONCLUSION

Failure to administer an appropriate bolus or 'loading dose' when administering morphine intravenously may result in ineffective and delayed pain management. The authors recommend more clearly defined protocols be developed to guide the use of morphine sulphate by paramedics in the local emergency medical services environment.

LPA5 receptor plays a role in pain sensitivity, emotional exploration and reversal learning

Lysophosphatidic acid (LPA) is a bioactive lipid acting on the nervous system through at least 6 different G protein-coupled receptors. In this study, we examined mice lacking the LPA5 receptor using an extensive battery of behavioral tests. LPA5-deficient mice showed decreased pain sensitivity in tail withdrawal, faster recovery in one inflammatory pain procedure (complete Freund's adjuvant-induced inflammation) and attenuated responses under specific neuropathic pain conditions. Notably, deletion of LPA5 also induced nocturnal hyperactivity and reduced anxiety in the mutant mice. Several exploratory tasks revealed signs of reduced anxiety in LPA5 knockout mice including increased visits to the arena center and reduced thigmotaxis in the open field, and more open arm entries in the elevated plus maze. Finally, LPA5 knockout mice also displayed marked reduction in social exploration, although several other tests indicated that these mice were able to respond normally to environmental stimuli. While learning and memory performance was not impaired in LPA5-deficient mice, we found differences, e.g., targeted swim strategy and reversal learning, as well as scheduled appetitive conditioning that might indicate differential motivational behavior. These results imply that LPA5 might be involved in both nociception and mechanisms of pain hypersensitivity, as well as in anxiety-related and motivational behaviors. These observations further support the proposed involvement of LPA signaling in psychopathology.

Emergency nurses' perceived barriers to demonstrating caring when managing adult patients' pain

INTRODUCTION

Pain is the most common presenting complaint in emergency departments and the primary reason patients seek medical care and take prescription medications. Improving inadequate pain control is a critical goal in emergency health care. As patients' primary health care advocates, emergency nurses play a vital role in resolving under-treated pain in their patients. The purpose of this qualitative study was to explore the perceptions of ED nurses regarding the processes used when managing adult patients' pain and to increase understanding of how these perceptions affect patients' pain management.

METHODS

Participants were recruited from the membership of the local emergency nurses association and 6 hospital-based emergency departments in Northeast Florida. Fifteen emergency nurses with tenure ranging from 1 to 35 years were individually interviewed. Interviews were transcribed verbatim and analyzed using content analysis methodology.

RESULTS

The central core category that emerged highlighted the ED environment as a barrier to demonstrating caring when managing adult patients' pain. The core category was supported by 3 broad themes, each consisting of 3 subcategories: (a) feeling overwhelmed as a result of constant prioritizing and perceived lack of control and adequate staffing, (b) perceived non-cohesiveness of the health care team, including nurses, administrators, and emergency physicians, and (c) frustration concerning abuse of the emergency department, complexity of pain, and unrealistic patient expectations of the nurses' role.

DISCUSSION

Interventions that improve the ED environment and facilitate the process of pain management are warranted. Implications for accomplishing these interventions clearly exist in nursing education, practice, research, and public policy.

Critical care nurses' experiences: "a good relationship with the patient is a prerequisite for successful pain relief management"

There is a lack of studies describing how critical care nurses experience assessing and treating pain in patients receiving postoperative care in an intensive care unit (ICU). The aim of this study was to describe those experiences. Qualitative personal interviews with six critical care nurses in an ICU in northern Sweden were conducted during 2009. The interview texts were subjected to qualitative content analysis, which resulted in the formulation of one theme and four categories. It was important to be able to recognize signs of pain in patients unable to communicate verbally. In older patients, anxiety could be interpreted as an indication of pain. Pain was primarily assessed by means of a visual analog scale. Being unable to treat pain successfully was experienced as failing in one's work. Pharmacologic treatment was always the first choice for relief. The environment was experienced as a hindrance to optimal nursing care, because all postoperative patients shared a room with only curtains between them. The work of assessing and treating pain in patients receiving postoperative care is an important and frequent task for critical care nurses, and knowledge in the field is essential if the patients are to receive optimal nursing care and treatment. Patients cared for in an ICU might benefit from nonpharmacologic treatment. Being without pain after surgery implies increased well-being and shorter hospitalization for the patient.