LEEDS TEACHING HOSPITALS NHS TRUST

EMERGENCY DEPARTMENT ACUTE PAIN MANAGEMENT GUIDELINES

LEAD AUTHORS

Heather McClelland Natasha Walters

Lecturer Practitioner, Advanced Clinical Pharmacist ED

Heather.McClelland@leedsth.nhs.uk Natasha.Walters@leedsth.nhs.uk

CONTRIBUTORS

Julie Walker – Sr. ED, Taj Hassan – Consultant, ED; Graham Johnson – Consultant, ED; Shirley Wilson – Senior Nurse, ED; Anna Di Biasio – Senior Nurse, ED, Jo Bagley - Senior Nurse, Acute Pain Team.

AIM

To provide a consistent, reliable and evidence-based approach to analgesic medicines management across the urgent and emergency services at the Leeds Teaching Hospitals NHS Trust (LTHT).

OBJECTIVES

· To identify a framework for prescription, administration and supply of analgesic medicines in line with other Trust documents and best evidence.

· To identify a training and auditing procedure to effectively implement and review the guideline.

· To explain the ratification process for this guidance.

SCOPE OF THE GUIDELINE

This document relates to the management of all patients, both adults and children, who attend the Emergency Departments (ED) with acute pain originating from any source. The ‘Emergency Departments’ descriptor incorporates all units within the service including Emergency Departments, Minor Injuries Units, Walk-In Centres, Clinical Decision Units, and Multi-Specialty Assessment Areas.

There are separate guidelines for adults and children, although there is crossover for those patients aged 12-16yrs.

The document applies to the management of pain by all professional groups within the emergency service, including doctors, nurses, and other professionals working in the departments. Specialist teams prescribing or administering medication within the service will be made aware of the guidelines.

These guidelines will change in line with any review of Trust Adult and Paediatric Pain Guidance.

GUIDANCE

Adult and paediatric recommendations are divided in three sections

· Recommended drugs for each category of pain – mild, moderate, severe (Table 1,2)

· Special case considerations – e.g. management of dislocated joints, or back pain. (Table 3)

· Other drug considerations (Table 4)

· Formulary of available medications (Appendix 1)

PATIENT ASSESSMENT

· Pain will be initially assessed as part of a complete physiological assessment when the patient presents to the department. Parents/guardians will be involved in the assessment process.

· All patients will have pain scored – using either the Manchester Triage Pain Ladder or the LTH Trust Pain Intensity Score – and documented on the ED card.

· All children will have their current weight documented on the ED card and any other prescribing documents.

EVALUATION

· Pain management should be evaluated at 20mins, 1hr and on discharge/admission from the ED, and appropriate actions taken, and documented.

DISCHARGE

· Discharge prescription and supply under PGD should follow this guidance accounting for patients’ current and ongoing needs.

· NSAID prescriptions on discharge – all patients over 65yrs, those on concurrent low-dose Aspirin, and other patients considered high risk of GI bleed, should be prescribed supplemental Lanzoprazole. See Trust guidance on Reduction of GI Mortality with NSAID Prescribing

GUIDELINE CONSIDERATIONS

· Non-pharmacological methods of pain management should be implemented to support patient care.

· This document is written as a guide to analgesic prescription, and is not exclusive. Other drugs available in the department, e.g. combined analgesics, show no beneficial effect over those recommended, but may be used at the discretion of the individual prescriber.

· Other routes of administration may be considered in specific circumstances, e.g. unable to gain IV access, under the discretion of the prescriber.

· Choice of analgesic agent is dependent on indications/contra-indications as per BNF/ Children’s BNF/Appendix 1

· Opioid-induced nausea/vomiting - effectively titrated intravenous (IV) opioid rarely induces nausea and/or vomiting. Anti-emetics to be considered include Cyclizine (1st line), or Ondansetron (unlicensed)

PAIN SCORE

INITIAL

ONGOING

Mild –

Trust Pain Intensity Score – 1

Manchester Ladder 1-3

Paracetamol 1g (PGD)

Or either

Ibuprofen 600mg (PGD) or Diclofenac 50mg

Any of the Initial Drugs not used

Or

Codeine Phosphate 30mg (PGD)

Moderate –

Trust Pain Intensity Score – 2

Manchester Ladder – 4-7

Anticipation of Mod. Pain

Uncontrolled Mild Pain

Paracetamol 1g (PGD)

And one of either

Ibuprofen 600mg (PGD)

Diclofenac 50mg

Or

Codeine Phosphate 30mg (PGD)

Any drugs not previously given at initial assessment.

Or

Morphine – Oral/IV

Severe -

Trust Pain Intensity Scale – 3

Manchester Triage Ladder – 8-10

Anticipation of Severe Pain

Uncontrolled Mod. Pain

Paracetamol 1g (PGD)

And

Codeine Phosphate 30mg (PGD)

And one of either

Ibuprofen 600mg (PGD) or Diclofenac 50mg

Or

Morphine Sulphate IV

Diclofenac 100mg PR (PGD)

And/Or

Entonox (PGD)

Any drugs not previously given at initial assessment

Ongoing severe pain must involve the senior medical/nursing team.

Table 1 – Adult Pain Management

PAIN SCORE

INITIAL

ONGOING

Mild –

Trust Pain Intensity Score – 1

Manchester Ladder 1-3

Paracetamol 20/30mg/kg (PGD)

(30mg/kg loading dose only)

Ibuprofen 5mg/kg (PGD)

Any of the ‘Initial’ drugs not previously used

Or

<12yrs - Dihydrocodeine 500micrograms-1mg/kg

>12yrs – Codeine Phosphate 30mgs (PGD)

Moderate –

Trust Pain Intensity Score – 2

Manchester Ladder –

4-7

Anticipation of Mod. Pain

Uncontrolled Mild Pain

Paracetamol 20/30mg/kg (PGD)

(30mg/kg loading dose only)

And either

Ibuprofen 5mg/kg (PGD)

Or

<12yrs - Dihydrocodeine 500micrograms-1mg/kg

>12yrs – Codeine Phosphate 30mgs (PGD)

Any of the ‘Initial’ drugs not previously used

Or

Morphine – Oral/IV – 0.1mg/kg

(See Table 5)

Severe -

Trust Pain Intensity Scale – 3

Manchester Triage Ladder – 8-10

Anticipation of Severe Pain

Uncontrolled Mod. Pain

Paracetamol 20/30mg/kg (PGD)

(30mg/kg loading dose only)

And

Ibuprofen 5mg/kg (PGD)

And either

Morphine Sulphate Oral - 200-400 microgram/kg

Morphine Sulphate IV- 100microgram/kg

Diamorphine Intranasal 100mcgs/kg

<12yrs - Dihydrocodeine 500micrograms-1mg/kg

And/Or

Entenox (PGD)

Any of the ‘Initial’ drugs not previously used

Ongoing severe pain must involve the senior medical/nursing team.

Table 2 – Paediatric Pain Management

Specific Patient Groups

PATIENT GROUP	CONSIDERATIONS
#NOF	Consider strong analgesics prior to movement – i.e. before X-Ray and transfer to ward. See LTHT #NOF Guidelines
Disclocated joints – shoulders, elbows, fingers	May require conscious sedation for relocation, therefore use of non-opoid analgesics recommended. If appropriate, also consider Local Anaesthetic block (at arrival if possible). See ED Conscious Sedation Guidelines
Back Pain	May need supplemental Diazepam prescribed with initial analgesics. N.B. Discharge – 2-3 days supply only See ED Back Pain Guidelines
Abdominal Pain	· Anti-Spasmodic – consider Buscopan Oral/IM/IV, or Mabeverine Oral · Cholecystitis – caution - pain may be aggravated by Morphine Sulphate
Headache	Migranes – consider use of Aspirin 900mgs, with anti-emetic, or a Triptan (local policy) when other treatments have already been instigated.
Trauma	Morphine Sulphate recommended as first-line analgesic in major trauma. Consider Local Anaesthetic blocks.
Eyes	Consider Tetracaine Hydrochloride 1% (PGD) on patient assessment
ENT	Consider use of Lidocaine 5%/Phenylephrine 0.5% spray
Renal Colic	Consider use of Diclofenac 100mg (PR) (PGD)
Foreign Bodies	Consider the use of topical anaesthesia (PGD) prior to removal of foreign bodies, e.g. piercings.

Table 3

Other Drug Considerations

Drug	Notes
Dihydrocodeine	May be used as an alternative to Codeine Phosphate, although it is currently classed as a Controlled Drug in the Trust ED service, and is used mainly in the management of addiction in in-patients
Tramadol	NOT to be initiated in the ED for acute pain, but may be used for those patients who are prescribed Tramadol in the community.
Co-Codamol 8/500	Should be considered for patients in whom a 30mg dose of Codeine Phosphate is thought to be too high, e.g. elderly.
Paracetamol IV	This is currently under review across the Trust. Use in the ED is being considered, and guidance will be updated accordingly.

Table 4

NOTES ON PAEDIATRIC GUIDANCE

· Paracetamol 30mg/kg is a loading dose ONLY, for those children who have not had any Paracetamol in the previous 24hrs.

· Patients receiving Intranasal Diamorpine should also receive Paracetamol (PGD) and Ibuprofen (PGD) to supplement short-term analgesic effect of Diamorphine.

· Intranasal Diamorphine is given as a once only dose – see departmental guidance

· Children receiving Intranasal Diamorphine, or Oral Morphine Sulphate should have topical anaesthesia (PGD) applied at initial assessment if ongoing pain management is anticipated.

· If manipulation/distressing procedure anticipated, early prescription of sedation may be appropriate.

· Burns – ensure adequate analgesia and dressings are initiated early in presentation. Consider Entonox

· Advise parents/guardians to give analgesic medication approximately one hour prior to clinic appt. for dressings for burns, finger dressings etc.

· Opioid-induced nausea/vomiting - effectively titrated intravenous (IV) opioid rarely induces nausea and/or vomiting. Anti-emetics, although mainly unlicensed, to be considered include Ondansetron (1st line) or Cyclizine.

REFERENCES

BAEM (2006) Standards for Emergency Departments.[Online] [Accessed 7^th March, 2007] Available World Wide Web: http://www.emergencymed.org.uk/BAEM/CEC/assets/Summary_of_Standards_Jan2006.pdf.

Bandolier Extra (2005) Combination Analgesics [Online]. [Accessed 30^th Jan. 2007]. Available from World Wide Web: http://www.jr2.ox.ac.uk/bandolier/Extraforbando/combo.pdf.

Bandolier Pain Research (2004) Easy Targets Aren’t Always the Right Ones. [Online]. [Accessed 1^st Jan. 2006] Available from World Wide Web: http://www.jr2.ox.ac.uk/bandolier/painres/combos/comboed.html.

BMA/RPSGB (2006) British National Formulary: 52 RPS Publishers, Biggleswade.

BMA/RPSGB/RCPCH/NPPG (2006) British National Formulary for Children. RPS Publishers, Biggleswade.

Pain Management Service (2002) Adult Acute Pain Management Guidelines. Leeds Teaching Hospitals NHS Trust, Leeds

HEALTH RISKS/BENEFITS

This guideline aims to

· provide excellent patient comfort, and experience

· ensure consistency of pain management across the service

· ensure speed of administration of analgesia

· aid diagnosis and assessment/evaluation of patient

· promote monitoring and ongoing pain management

There are no known risks to the implementation of this guideline. No new drugs will be purchased to support the document, as it relates to those drugs currently used within the departments.

INTERNAL REVIEW

Clinical Governance Team – A&E CMT; Paediatric leads (medicine and nursing) both EDs; LTH Trust Acute Pain Team - Adult and Paediatric.

Changes have will be made to the document based on the comments made by these teams.

IMPLEMENTATION

All departmental staff will receive training in the document, and copies of the document will be available in medical and nursing guideline resources – including the Emibank website.

It will be the responsibility of the senior team, both medical and nursing, to address issues of compliance and support ongoing training of staff.

FORMAL REVIEW

Pain management will be audited against this guideline and the BAEM standards one year after approval, and recommendations for practice made.

Formal review and ratification by the Clinical Governance Team and the authors will take place two years from the date of approval.

Date of Approval

…………………………

Signatures of Approval

Authors

……………………………… …………………………………

Heather McClelland Natasha Walters

Lecturer Practitioner Advanced Specialist Pharmacist

……………………………… …………………………………

Dr Graham Johnson Shirley Wilson

Clinical Lead Matron – ED Services (Acting)

……………………………….

Jackie Whittle

Deputy Chief Nurse (Acting)

Appendix 1. Absolute and Relative Contraindications to Administration and Supply

of Analgesic Drugs for use with the ED Acute Pain Management Strategy.

1of 3

Drug

Contraindications to Administration AND Supply

Contraindications to Administration

(A Supply may be given for use

at home later if required

or appropriate to drug)

Absolute for PGD and should be considered when prescribing

Relative Contraindications to Administration AND Supply.

(For PGD advice contact Dr/Pharmacist/Member of Medicines Information staff)

Relative for PGD and should be considered when prescribing

Paracetamol

· Allergy / Hypersensitivity to paracetamol

· Recent dose (within the last 4 hours) of paracetamol or other paracetamol containing preparation

· Not more than 3g paracetamol in the last 24 hours

· Pregnancy

· Breast feeding

· Renal impairment

· Hepatic impairment

· Alcoholism

Codeine

· Allergy / hypersensitivity to codeine

· Head injury

· Recent dose (within the last 4 hours) of codeine or co-codamol.

· Recent dose of other opiate containing analgesic

· Concurrent antipsychotic, anxiolytics, hypnotic medications

· Pregnancy

· Breast feeding

· Renal impairment

· Hepatic impairment

· Alcoholism

Ibuprofen

· Allergy / hypersensitivity to ibuprofen, aspirin or other NSAIDs

· Epigastric pain

· Dyspepsia

· History of, or active peptic ulceration

· Recent dose (within the last 6 hours) of ibuprofen, ibuprofen containing preparation

· Recent dose (within the last 12 hours) of long acting ibuprofen

· Recent dose (within the last 6 hours) of other NSAID (excluding aspirin 75mg)

· Recent dose (within the last 12 hours) of other long acting NSAID

· Concurrent medications (not HRT, oral contraceptive pill and other analgesics in the ED Acute Pain Management Strategy

· Elderly, >65 years old

· Asthma

· Heart failure

· Pregnancy

· Breast feeding