PHARMACOLOGY OF EMERGENCY DEPARTMENT PAIN MANAGEMENT AND CONSCIOUS SEDATION
Section snippets
PAIN MANAGEMENT
Appropriate treatment of pain and anxiety is a major portion of the practice of emergency medicine. Nearly all studies to date have demonstrated that physicians are poor at adequately treating pain. The usual reasons cited for this inadequate administration of analgesics are concerns of adverse affects such as respiratory depression with higher dosages, and addiction with prolonged treatment courses. The term oligoanalgesia was coined to describe the underutilization of analgesics to treat
TYPES OF MEDICATIONS
There are three major classes of analgesic medications available: opioids, nonopioids (including aspirin, acetaminophen, and other nonsteroidal antiinflammatory drugs [NSAIDs], and a third category of medications not normally considered analgesics, that either act as adjuvants when combined with opioid or nonopioid medications, or that have intrinsic analgesic activity with some types of pain.
CONSCIOUS SEDATION
The term conscious sedation is commonly used to describe the process of providing analgesia, sedation, and amnesia for patients undergoing painful procedures, although its inconsistent definition has been described as misleading.44, 60, 80 A more precise and therefore preferred term is procedural sedation and analgesia. In a recently published American College of Emergency Physicians' clinical policy, procedural sedation was defined as
a technique of administering sedatives or dissociative
Midazolam
Midazolam is a benzodiazepine commonly used in the ED to provide sedation. It is also used in the treatment of generalized seizures and behavioral emergencies, and as an induction agent in rapid sequence intubation.66 It is particularly popular in procedural sedation owing to its rapid onset and short duration of action.
Midazolam belongs to a new class of benzodiazepines, the imadodiazepines. The addition of an imidazole ring to the benzodiazepine nucleus has led its unique pharmacokinetic
PREVENTION OF DRUG-RELATED COMPLICATIONS
Appropriate selection and dosing of medications with a good understanding of their pharmacologic actions can minimize complications. Appreciation of potential drug interactions is crucial. A written consent should be obtained before procedural sedation and analgesia is begun.44, 45 A thorough evaluation of the patient, specifically including airway assessment and the patient's physiologic reserve, should be performed prior to the initiation of procedural sedation and analgesia.2, 44, 45 Recent
SUMMARY
The endpoints of sedation and analgesia have been more difficult than traditional physiologic parameters to measure adequately.9 Several clinical scoring systems have been developed in an attempt to provide more consistent and objective assessments of sedation, but the few that have been validated are cumbersome to use in the clinical setting and cannot accurately determine subtle changes in the level of sedation.9, 23 Recent developments in EEG monitoring, particularly one using bispectral
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Approach to Pain Management
2008, Pediatric Emergency MedicineApproach to Pain Management
2007, Pediatric Emergency MedicinePropofol by infusion protocol for ED procedural sedation
2006, American Journal of Emergency MedicineManagement of chronic pain in the acute care setting
2005, Emergency Medicine Clinics of North AmericaCitation Excerpt :Treating pain “aggressively and effectively” may include the use of opioids for acute or postsurgical pain, but may exclude opioids for many chronic pain patients. The term “oligoanalgesia” has been used to describe the undertreatment of pain, which has been reported to occur in emergency departments [107]. Opioids are very effective for treating pain during the relatively brief acute and recovery phases of injury or illness.
Procedural sedation and analgesia in the Emergency Department: What are the risks?
2005, Emergency Medicine Clinics of North AmericaCitation Excerpt :Given the advanced training of the emergency physician in airway management, vascular access, resuscitation, and pharmacology (of PSA and PSA reversal drugs), the incidence of adverse events are not likely to be higher when an adequate amount, type, and combination of PSA drugs are used with the goal of lower failure rate in mind. The armamentarium of PSA agents available to clinicians today makes the scenario of increased patient satisfaction without increased adverse events possible by allowing for avoidance of agents with unpredictable and life-threatening side effects [4]. Pena et al [5] found the adverse event rate PSA was 2.3% in an urban pediatric ED, although none required intubation or admission.
Address reprint requests to Paul Blackburn, DO, FACOEP, FACEP, Department of Emergency Medicine, Maricopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008