1. 1 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh “ I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being.” Dr Mohammed Ohidul Alam FCPS FRCSI FRCSEd MRCSEd(A&E) FCEM(London) Consultant Emergency Medicine Conquest Hospital United Kingdom

2. Do children get Pain ? Do elderly get pain? Yes, They do!!!!! A-fiber 10- 20m/sec C-fiber 1 m/sec 2 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh

3. 3 CEM standards for analgesia are for Severe pain Moderate pain in 20 mins 50% in 30 mins 75% 75% in 60 mins 98% 90% Definition: The term pain is a subjective experience that typically accompanies nociception.

4.  Why pain is a priority? ◦ Pain is a very unpleasant, sensation to all human beings and therefore control of pain in the ED is a priority’ ◦ Short and long term effect of pain  Potential deterioration  Systemic effects on body  Acute psychosis &  chronic post-traumatic stress disorder Few facts to consider Commonest presenting symptom is pain. 60% Pain is commonly under recognized. Commonly under-treated and even treated late. EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh. 4

5.  When a patient in pain enters the ED he or she has two main concerns (not necessarily in this order): ◦ 1. How quickly can I get relief from my pain? ◦ 2. What is causing this pain?  The major concern of professionals are: ◦ 1. What is the diagnosis? ◦ 2. What is the treatment for the underlying disease process? EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh 5

6.  Triage ◦ Pain score recording ◦ Recording vital signs ◦ To get Idea of potential problem ◦ Priority to be seen by doctor ◦ Giving pain relief if necessary. 6 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh.

7. 7 Pain pathway: The main pathway ascends through the dorsal horn of the spinal cord, crosses the midline to the opposite side of the spinal cord, and reaches the brain’s thalamus through the anterolateral white matter. From the thalamus, the signal is transmitted through the third order neuron to the somatosensory cortex.

8. EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh. 8 How to measure Pain score ?

9. 9 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh Analgesics: By definition any drug which alleviates pain without loss of consciousness is called an analgesic.

10. Assess pain severityAssess pain severity Administer analgesiaAdminister analgesia within 20 minutes within 20 minutes Mild pain (1-3) Oral/rectal paracetamol 20mg/kg loading dose, then 15mg/kg 4-6 hourly Or ibuprofen 10mg/kg 6-8 hourly Moderate pain (4-6) Oral/rectal diclofenac 1 mg/kg 8 hourly (unless already had ibuprofen) And/or Oral codeine phosphate 1mg/kg 4-6 hourly Severe pain (7-10) Consider entonox as holding measure as holding measureThen Intranasal diamorphine 0.2 mls (0.1 mg/kg followed by/or IV morphine 0.1-0.2 mg/kg supplemented by oral analgesic 10 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh

11. EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh. 11

12. . 12

13. Fracture NOF Audit 2009 by CEM  5,543 #NOF cases from 113 emergency departments (ED) were included in the 2008 audit. Nationally,  10% of audited patients received adequate pain relief before arrival,  22% within 20minutes of arrival,  30% within 30 minutes and  52% within 60 minutes of arrival in A&E. EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh.. 13

14. Paediatric Pain Audit 2009 by CEM  5,543 cases from 117 emergency departments were included in the 2008 audit Nationally, 42% of audited children received pain relief within 20 minutes of arrival,  55%within 30 minutes and  69% within 60 minutes of arrival in ED. EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh.. 14

15.  Murice et all EMJ 2001, Current Practice in Paediatric Analgesia, part 1 ◦ Southal, 181 Invasive procedure, ◦ 28% adequate analgesia ◦ Schechter 90 adult/90 children ◦ ½ number doses of analgesic ◦ Friedland, 99 Children, ◦ 53% Rx adequate analgesic ◦ Children < 2yrs age less likely to have analgesics 2nd International Conference on Emergeny Medicine in Dhaka, 1st to 3rd january 2010.15

16. Intranasal Diamorphine Vs IM Morphine  Wilson & Kendall, EMJ 1997, ◦ Safety & Efficacy of Paediatric Intranasal Diamorphine vs. IM Morphine: ◦ Total Children 58, complete data 51(88 %) Jason & Kendall, BMJ 2001, Multi centre trial, RCSEn’g, Bristol Children H & UCL London EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh 16 Total: 404 children, Age 3-16 Yrs, 204, given Intranasal Diamorphine 200 given IM Morphine No Discomfort 95% Vs &71% Acceptability 98% Vs 32% Side effects Similar

17.  Intra Nasal Diamorphine: Advantages ◦ Easy Administration ◦ Quick onset of effect ◦ Good Bioavailability ◦ Very Effective pain control ◦ Can be top up easily 17 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh

18. Opiates Morphine (0.1mg/kg) Intranasal diamorphine ( 0.1mg/kg) Well tolerated Onset 5 min, max effect at 1 hr Duration 4 hours Similar side effect like IM Morphine 18 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh

19.  Other Analgesics ◦ Entonox (NO2 50% & O2 50%) ◦ Fentanyl ◦ Midaziolam Oral 0.500mg/kg & no >15mg  Local anaesthetic: ◦ Injections, Spray or Cream ◦ Lidocaine, Amithocaine, Prilocaine  Sedation by:  KetamineNon Pharmacological  propofol 19 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh.

20. 20 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh.

21. In Summary: 1.Pain control is of priority in ED 2.Triage nurse to determine the pain score 3. Choosing right drug for right patient 4. Delivering the drug in right route 5. Often combination of drugs required 6. Initiating initial treatment immediately and 7. Facilitating definite care sooner. EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh. 21

22. 22 EMCON 3, 29 th December 2010 to 1 st January 2011, Dhaka, Bangladesh.. ‘ Lets be a trustworthy friend to our patients by making the in-hospital stay as comfortable as possible, so that we can remembered in a sweeter way for ever ’.