David D. Nicolaou
Principles. pfConscious,, Sedation Assessment .of Patients Pharmacology Analgesics
Anesthetics AdjunctiveAgents Antidotal. agents Discharge Pp|icy..lssues
Clinical ..Standards. .a,nd,..,D,oc,u,m,entati,on Costs
Pain is either the chief complaint or is implicit in the chief complaint of many patients who seek care in the emergency department (ED). The recognition of its significance is sufficiently widespread that it has been included in the list of symptoms comprising the "prudent layperson" statutory definition of a medical emergency. The treatment of pain is therefore the essence of emergency medicine practice.
The provision of analgesia by physicians has historically been inadequate, and this has been shown to be true in the ED. A study of 198 patients admitted with acutely painful conditions found that only 89 (44 percent) received analgesics in the ED. Of these, 69 percent waited more than 1 h and 42 percent waited more than 2 h for opioid analgesia.1 Similar findings have been demonstrated in other ED studies of pain treatment, both in the United States and abroad. 23 "Oligoanalgesia," the term coined by Wilson and Pendleton to describe the inadequate use of opioids to treat pain, unfortunately is often still present in EDs. Patients likely to receive inadequate analgesia include those over 70 years of age 4 and members of certain ethnic groups.5 There is conflicting evidence, though, as to whether age is a factor. 6
The reasons for inadequate analgesia are numerous. Minimal attention to pain management in medical school and residency, concern about narcotic diversion, abuse or addiction, and a limited understanding of analgesic pharmacology have all been hypothesized to contribute to "oligoanalgesia" in the ED. Physical evidence of distress, such as facial expressions and pulse rate, correlates poorly with the patient's perception of pain. 7
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