1. Taravat Fakheri

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3.  The most common symptom to (ED)  Assessment of severity of pain is subjective,  All rely on patients’ perception  Pain can be divided into two major categories, acute and chronic.

4.  Serves a physiologic function; a warning to the patient that something is wrong,  Transition point from acute to chronic variably defined, ranging from as little as 4 to 6 weeks up to 6 months of pain.

5.  No useful function to the pt.  1-2ary to diseases as cancer, sickle cell disease, and AIDS;  2-Known pain syndromes as tic douloureux & migraine headache;  3-Without an identifiable cause;  4-Those complain of chronic pain to obtain drugs or for other personal gains.

6.  1-Cancer patients with new pain or with acute worsening of their previous pain should be evaluated for a new complication and their pain aggressively managed with opiates.

7.  2-Patients with known pain syndromes and without objective cause for their pain require an aggressive team approach.  ex; patients with sickle cell disease and frequent pain.

8.  3-those who test the patience and professionalism of emergency physicians and nurses.  The majority of these patients are seeking narcotics.

9.  4-Malingering Dx by exclusion,  One approach ; use butorphanol (Stadol), good analgesic activity but little euphoria.  (NSAIDs) offered, but these patients will often refuse them or state that they cannot take them..

10.  Pain is a combination of physical, chemical, and psychological factors.  Quantify the patient’s perception of the degree of pain.  Verbal report is the only way to reliably obtain a patient’s evaluation of the pain.

11.  As part of the triage process, and should be located on the record where the vitals are recorded.  Record severity of pain during the initial assessment process, and early and effective management of pain should be ensured.

12.  After treatment, the assessment should be repeated as needed.  Studies have documented inadequate use of analgesic agents in the ED esp in the pediatric population.  Many patients do not receive any pain medications while in the ED, even though their primary presenting complaint was pain

13.  Inadequate use of analgesics in the ED.  Use of wrong agent; inappropriate dosage and dosing intervals or route of administration;  improper use of adjunct agents;  Concern for medically induced addiction to narcotics.

14.  Failure to give analgesics is an issue that must be addressed by education of nursing staff and physicians.

15.  Adequate pain relief for all patients.  Patient satisfaction may be directly related to adequate pain control.

16.  Early control of acute pain reduces the incidence of chronic pain syndromes, and may improve the patient’s outcome.  Finally, health-care providers have taken an oath to reduce or prevent pain and suffering.

17.  Requires physician reeducation,  Major changes in practice habits

18.  Parenteral opioids.  IV line  Dosage titrated  Amount vary widely from patient to patient

19.  Efective level varies as eight times greater from one patient to another.  IM should be avoided, painful and the onset of action is variable.  If an IV cannot be obtained,SC an excellent alternative.  Newer agents ; sublingual or nasal route.

20.  Available in sucker form, which has great applicability in the pediatric population.  Sufentanil and butorphanol, both potent opioids, effective via the nasal mucosa.  Once the route and dosage are determined, the analgesic should be given at frequent enough intervals to prevent the return of pain

21.  little role for adjunct agents in acute pain in the ED.  Exception; persistent nausea and vomiting following the use of opioids, or  pain + nausea and vomiting.

22.  Using an adjunct to reduce the opioid dose simply is not valid and exposes the patient to another set of side effects. This practice should be abandoned.  The risk of addiction to the opioids with medical use must be a concern for physicians, especially when treating with chronic pain  less in acute pain.

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24.  Many of these patients are women of childbearing age or pregnant  Providers evaluating such patients should be familiar with the common causes of abdominal pain in pregnant women 24

25.  Up to 80% of women experience nausea and vomiting during pregnancy  Symptoms and signs that may indicate another cause for nausea and vomiting:  Symptoms past 20 weeks  Associated with abdominal pain, fever, or diarrhea  In these instances, a more thorough evaluation is indicated 25

26.  Warning signs that the cause may be nonpregnancy related:  Pain localized, abrupt, constant, or severe  Pain associated with nausea and vomiting, vaginal bleeding, or fever  If any of these are present, further investigation is warranted and consultation with an obstetric specialist is recommended 26

27.  All women of childbearing age who present to the ED should have a urine pregnancy test  If pregnant, the location and gestational age of the pregnancy should be determined with ultrasound  Abortion & EP are the most common causes of pain in early pregnancy  Both often also present with vaginal bleeding 27

28.  In general, the cause and incidence of non- obstetric abdominal pain in pregnancy varies little by gestational age of the fetus  The most common causes of acute abdominal pain in pregnancy are (with incidences):  Appendicitis (1/1500 pregnancies)  Cholecystitis (1/3000)  Nephrolithiasis (1/3000)  Pancreatitis (1/3000)  Small bowel obstruction (1/3000) 28

29.  Hx,PE, pregnancy test, and ultrasound, certain laboratory tests may be helpful  Complete blood count  Liver and pancreatic enzymes  Urinalysis  If diagnosis is still uncertain, prompt imaging may be necessary 29

30.  Imaging in pregnancy should begin with ultrasound or MRI  Neither has ionizing radiation  Neither has been linked to fetal harm 30

31.  If diagnostic tests with ionizing radiation (e.g., computed tomography) are clinically necessary, they should not be withheld, even with concerns about fetal harm  Risk of harm to fetus is low, especially at lower radiation doses  The radiation delivered in a CT scan of the abdomen and pelvis is less than the dose known to cause fetal harm  As a rule, the smallest amount of ionizing radiation should be used  CT scan in this setting should only be obtained after obstetrical consultation 31

32.  Laparoscopy has become increasingly popular in the treatment and evaluation of acute abdomen.  pregnancy not a contraindication for laparoscopy,  Minimize manipulation of the uterus. 32

33.  ( A) Pregnancy Related Pain:  Early pregnancy o Abortion: Inevitable, incomplete or septic abortions o Vesicular mole: when expulsion starts. o Ectopic pregnancy: pain precedes bleeding.  Later pregnancy o Braxton-Hicks Contraction o Round Ligament Pain o Pressure symptoms o Cholestasis of pregnancy o Placental abruption o Placenta percreta o Acute Fatty Liver o Pre-eclampsia, HELLP o Spontaneous rupture of the liver o Uterine rupture o Chorioamnionitis o Acute Polyhydramnios o Labor ( Term, Preterm ) )

35.  Irregular,  Not progressively increasing  Not associated with bulging of forebag of water or dilatation of the cervix.  Respond to anlgesics  Cause women confusion as to whether or not they were going into actual labor.  They are thought to be part of the process of effacement, the thinning and dilation of the cervix

36.  The most common complication is the syndrome of ‘ painful myoma ’ ; this is due to red or carneous degeneration and occurs in 5 – 8% of myomas during pregnancy  This complication is associated with localized pain of rapid onset, nausea, vomiting and fever, tenderness, and an elevated white blood cell count  It usually occurs during the second trimester of pregnancy Red Degeneration Of A Uterine Myoma (syndrome of painful myoma )

37. with advancing gestational age as the uterine size increases. The round ligaments, found on the right and left sides of the uterus, attach to the pubic bone and help support the placement of the uterus in the abdominal cavity.

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