Emergency Room Pain Management Made Simple for Physicians and Patients

Simply asking the patient how they want their pain managed in the emergency room may be the key to managing pain effectively, according to research published in the Annals of Emergency Medicine.

Researchers from Montefiore Medical Center in the Bronx examined 207 adults with acute severe pain in order to assess the efficacy of a pain medication dose driven by the patient response to a yes or no question: “do you want more pain medicine?” The pain the patients had was defined as pain that required intravenous opioids in the judgment of the attending emergency room physician.

“The crowded conditions in most emergency departments in the US are not conducive to fully individualized pain treatment,” study author Andrew Chang, MD, MS, explained in a press release. “Our simple and easy to remember ‘1 + 1 + 1 + 1’ protocol holds promise for safely providing adequate pain relief to patients with acute severe pain.”

The researchers used 1 mg increments of intravenous hydromorphone given at fixed intervals when the patients responded affirmatively after 30 minutes after receiving their primary dose. The patients that responded no were not dosed, but were asked the question again 30 minutes later. Each patient was asked four times if they wanted more pain medication.

A total of 205 patients (99 percent) achieved satisfactory pain reduction at one or more points over the course of the study, the researchers said. There were 114 patients who received the initial dose of hydropmorphone, while 78 patients received 2 mg (one dose plus an additional dose). Nine patients received 3 mg (one dose plus two additional doses), and six patients received 4 mg (the initial dose plus three additional administrations).

All except for two patients achieved adequate pain control within two to four hours, or the entire study duration. Two thirds of patients reported being “very satisfied” and about a third reported being satisfied with their pain treatment.

“Pain perception is highly subjective and not necessarily correlated to pain scores,” Chang continued. “Our pain protocol is a departure from the more traditional ways of assessing pain relief, which typically use the visual analog scale or the numerical rating scale. Instead, our use of a non numerical, simple yes/ no question offers patients the ability to decide for themselves whether their pain is adequately controlled and allows them to balance pain relief against medication side effects such as nausea and drowsiness. This likely explains the wide range of pain scores (as much as 0 to ten) for patients who did not ask for pain medication.”

There were 9 patients desaturated below 95 percent on room air, with two patients having respiratory rates of less than 10 breaths per minute. An additional two patients had pulse rates of less than 50 beats per minute. The researchers added that there were no adverse events linked to the amount of hydromorphone received.