A 32-year-old pregnant woman at 29 weeks gestation presents to the ER with sudden onset of severe right flank pain radiating to her back and groin, associated with nausea and increased urination. On examination, her vital signs are stable. The fetal heart sound is normal and there is no vaginal bleeding. Preliminary tests have been ordered. The document discusses evaluating and treating pain using analgesics like paracetamol, NSAIDs, opioids, and adjuvants depending on the intensity of pain. Regional anesthesia techniques are also described. For this pregnant patient, the document recommends treating her pain with paracetamol, NSAIDs initially given her gestational age and pain description. Close monitoring

1. Pain Management

3. Case:
• A 32- year old G3P1 female at 29 weeks of gestation is brought to the
ER by her husband with complaints of sudden onset of right flank
pain from loin to groin. The pain is severe and radiates to the back, it
is associated with nausea and increased frequency of urination.
• On Examination:
Temperature: 36.2°C, BP: 120/80 mm Hg, HR: 99bpm, RR: 23/min
P/A: FHS is heard, Uterus is soft, no vaginal bleeding, Preterm labor is
ruled out
Preliminary baseline investigations are sent
How will you manage pain in this case?

4. “Pain is, with very few, if indeed any exceptions,
morally and physically a mighty and
unqualified evil. And, surely, any means by
which its abolition could possibly be
accomplished, with security and safety
deserves to be joyfully and gratefully
welcomed by medical science.”
Sir James Young Simpson, 1871

5. What is pain?
• Latin poena : “punishment, penalty”
• “An unpleasant sensory and emotional experience associated with actual
or potential tissue damage, or described in terms of such damage”
-International Association for the Study of Pain
• The specialty of pain medicine seeks not only to relieve pain, but to restore
function, and prevent or eliminate disability.

6. What happens if pain isn’t properly treated?
• Poor appetite and weight loss
• Disturbed sleep
• Withdrawal from talking or social activities
• Sadness, anxiety, or depression
• Physical and verbal aggression, wandering, acting-out behavior,
resists care
• Difficulty walking or transferring; may become bed bound

7. Common Misconceptions about Pain
• The caregiver is the best judge of pain.
• A person with pain will always have obvious signs such as moaning,
abnormal vital signs.
• Addiction is common when opioid medications are prescribed.
• Morphine and other strong pain relievers should be reserved for the
late stages of dying.
• Morphine and other opioids can easily cause lethal respiratory
depression.

9. Pain Evaluation
• History and physical examination:
Onset and duration
Site
Quality
Intensity
Radiation
Aggravating/relieving factors
Associated symptoms
Treatment response
• Ask patient to rate their pain:
• Asking about pain is an important part of ALL assessments!

10. Don’t ever forget:
• Pain is what a patient says it is
• Pain is totally subjective
• Pain is considered as “fifth vital sign”
• Self-report of pain is the single most reliable indicator of pain
• You cannot reliably detect its existence or quantify its severity
without asking the patient directly

11. How to rate pain?
A useful means of assessing pain and evaluating the
effectiveness of analgesia is to ask the patient to rate the
degree of pain along a numeric or visual pain scale
Methods:
• Numerical Rating Scale
• Faces Pain Scale
• Visual Analog Scale
• McGill Pain Questionnaire

12. Numerical Rating Scale:

13. Faces Pain Scale:

14. TREAT THE PAIN!

15. Also,
Check the efficacy of pain therapy
because there is a GOAL!

16. Considerations for pain relief:
• Splintage / Immobilization
• Elevation
• Massage
• Cold / Heat
• Meditation / Relaxation
• Acupuncture and electro-acupuncture
• Hypnosis
• Transcutaneous Electrical Nerve Stimulation (TENS)
Relives pain and decrease the requirement for analgesics drugs

17. Psychological aspects of pain relief
• Anxiety and distress accompany pain
• Psychological support
• Explain what is happening
• Show that you care
• Talk to the patient
• Make the room pleasant
• Provide support and reassurance
• Presence of family members or a close friend is often helpful

18. Analgesics:
Many different analgesic drugs are available,
but it is best to use only a few
and become familiar with
their actions, dosages, side effects,
and contraindications.
Consider drug allergies and interactions.

19. Commonly used pharmacological methods
• Paracetamol
• NSAIDs: Aspirin, Ibuprofen, Ketorolac, Diclofenac, Aciclofenac
• Opioids: Codeine, Tramadol, Morphine, Fentanyl
• Antispasmodic: Hyoscine Butylbromide
• Adjuvants: Antidepressants and anticonvulsants, Topical analgesics,
Muscle relaxants, Antianxiety medications
• Regional Anaesthesia

20. Who Analgesic Ladder

21. Paracetamol
• Inhibition of prostaglandin synthesis in the central nervous system
• Doses: 500mg – 1g every 4-6 hrs (maximum 2.5-4g per 24 hours)
• Routes: oral, intravenous
• Effective as both an analgesic and antipyretic
• Used for mild pain (Pain score 1-3)
• Risk: Hepatotoxicity
• Contraindications: in patients with heavy alcohol use acute/chronic
hepatitis

22. NSAIDs
• Most commonly prescribed analgesics
• Act by inhibiting COX-1 and COX-2 enzymes
• Results in a decreased production of prostaglandins from arachidonic
acid
• Uses: Analgesic, Antipyretic, Anti-inflammatory
• Effective for bone and inflammatory pain
• Commonly used via oral, topical, intramuscular route, IV available for
Ketorolac

23. NSAIDs
• Ketorolac: 15–30 mg i.m. or i.v. every 4–6 hours (max. 90 mg/
day) commonly used for postoperative, dental and acute
musculoskeletal pain, may also be used for renal colic, migraine
and pain due to bony metastasis
• Diclofenac: 50 mg TDS, then BD oral, 75 mg deep IM. Coomonly
used in rheumatoid and osteoarthritis, bursitis, ankylosing
spondylitis, toothache, dysmenorrhoea, renal colic,
posttraumatic and postoperative inflammatory conditions
• Aceclofenac: 100 mg BD

24. NSAIDs adverse effects
• Gastrointestinal: Abdominal pain, dysplasia, nausea, vomiting, and rarely,
ulcers or bleeding
• Central nervous system: Headaches, tinnitus, and dizziness
• Cardiovascular: Fluid retention hypertension, edema, and rarely, congestive
heart failure
• Hematologic: Rare thrombocytopenia, neutropenia, or even aplastic
anemia
• Hepatic: Abnormal liver function tests and rare liver failure
• Pulmonary: Asthma
• Rashes: All types, pruritus
• Renal: Renal insufficiency, renal failure, hyperkalemia, and proteinuria

25. NSAIDs
Precautions and Contraindications:
• Peptic ulcer
• Chronic liver disease
• Diabetics
• Pregnancy
• Breastfeeding mothers
• Sensitive to it

26. Antispasmodics
• Hyoscine Butylbromide is used to treat spasmodic, crampy abdominal
pain, renal colic, and bladder spasms
• Route: oral, IV or IM
• Dose: 20mg IV
• Side Effects: sleepiness, vision changes, allergies, triggering of
glaucoma

27. Opioids
• The naturally occurring alkaloid, morphine, is the prototype drug
• Decrease N.E , substance p in CNS synapses
• Decreases pain perception and increases pain threshold
• Used for moderate to severe pain
• Available to administer via various routes
• Specific opioid selection guided by intensity and duration of pain,
tolerance and safety
• Short acting opioids for acute pain

28. Opioids
ADVERSE EFFECTS
• CNS depression
Respiratory depression, sedation
• Histamine release(esp. morphine)
• Stimulates CTZ center in area postrema
• Abuse potential, tolerance, dependence

29. Opioids
Commonly used preparations
• Morphine: 10–50 mg oral, 10–15 mg i.m. or s.c. or 2–6 mg i.v.; 2–
3 mg epidural/intrathecal; children 0.1–0.2 mg/kg. i.m. or s.c.
• Tramadol: 25-50 mg IV, atypical opioid, used for moderate pain,
may cause dizziness, nausea, vomiting, headache

30. Adjuvant drugs
• Not typically pain medications
• May relieve discomfort
• Potentiate the effect of pain medications
• Reduce the side effect burden

31. Adjuvant drugs
• Antidepressants and anticonvulsants
• Topical analgesics
• Muscle relaxants
• Antianxiety medications

33. Pain type Typical initial drug treatment
headache Paracetamol, NSAIDs
migraine paracetamol, NSAIDs
menstrual cramps NSAIDs
minor trauma, such as a bruise, abrasions, sprain paracetamol, NSAIDs
severe trauma, such as a wound, burn, bone fracture, or
severe sprain
Opioids
strain or pulled muscle NSAIDs, muscle relaxants
minor pain after surgery paracetamol, NSAIDs
severe pain after surgery Opioids
muscle ache paracetamol, NSAIDs
toothache or pain from dental procedures paracetamol, NSAIDs
kidney stone pain paracetamol, NSAIDs, opioids
pain due to heartburn or gastroesophageal reflux disease antacid, H2 antagonist, proton-pump inhibitor
chronic back pain paracetamol, NSAIDs
osteoarthritis pain paracetamol, NSAIDs
fibromyalgia antidepressant, anticonvulsant

34. Regional Anaesthesia
• Cost effective
• Provide long and good quality analgesia
• Few side effects
• Central and peripheral blocks
• Can be done under Ultrasound guidance ± neurostimulation

35. Plexus and Nerve Blocks
• For management of localized pain
• Drugs used Lidocaine, bupivacaine, ropivacaine
• Concentrations (0.125-0.375 %) analgesic
• Duration 7-12 hours
• Success rate > 90%
• Side effects < 2 % (neuropathies, local anesthetic toxicity)

36. Back to our pregnant lady:
• What will you use now for pain management?

37. What means the work in ER?
• Acute pain is the reason majority of patients present to the ER
• Broad range of illnesses presenting with pain
• Increased workload
• Growing incidence of visits

38. Categories of illnesses presenting with pain in ER:
• Trauma
• Wounds
• Abdominal pain
• Headache
• Back and neck pain
• Chest pain
• Abscesses
• Renal colic

39. Poor management of painful conditions in ER
• Failure to acknowledge pain
• Failure to assess initial pain
• Failure to have pain management guidelines
• Failure to document pain
• Failure to assess treatment adequacy
• Failure to meet patient’s expectations
• Concerns regarding opioid addiction and abuse
• Fear of opioid side effects

40. I hope you will remember that
• Pain is the common reason for coming to ER
• Pain is undertreated in ER
• Pain as the fifth vital sign SHOULD BE MONITORED!
• Pain level must be reassessed after first therapeutic attempt

41. Thank You!!