Pain management (acute) ⚠️

• Acute (nociceptive) pain usually has an obvious cause (eg burn, impact injury, appendicitis) and is expected to get better with tissue healing
• Pain treatment involves the use of non-pharmacological (eg heat or ice packs) and pharmacological (eg analgesics) interventions
• Treatment aims to provide comfort rather than total resolution (stopping) of pain
• Always consider comorbidities, side effects and drug interactions when managing pain
• Good response to analgesia does not exclude significant infection or illness

Ask

• When did the pain start, how long
• Where does it hurt. More than one place, does it move
• All the time, coming and going, if ever completely comfortable
• Had it before, what happened then
• Dull, sharp, cramping, squeezing pain or discomfort
• What they think causes pain
• What makes it worse, eg movement, rest, time of day
• What makes it better, eg rest, medicine, ice, heat, activity
• About pain score on a scale of 0 no pain to 10 worst ever or use face scale — Figure 7.1

Check

• U/A, pregnancy test 
• Head-to-toe exam

Do

• Treat underlying condition or injury
• Communicate with patient and family to reduce fear and anxiety
• Position for comfort
• Consider heat and/or cold therapies
• Consider relaxation and/or distraction techniques
• Give pain relief — check specific requirements for each medicine
• Reassess pain level regularly

Pain Medicines

You must know your organisation's policy about which pain medications can be initiated (started) by a RN or ATSIHP 

Paracetamol

• Do not give for fever if no pain or discomfort or child not miserable — can make some viral sicknesses last longer
• If ongoing pain — regular doses are better than waiting for pain to get very bad — consider using slow-release paracetamol
• Double dose can be given at night — then no more for next 8 hours

Adult

• Do not give more than 8 tablets (500mg) or 6 tablets (665mg) in 24 hours
• If fasting, known liver disease, regular or heavy user of alcohol — reduce dose to 4–6 tablets  (500mg) in 24 hours

Child

• Child dose — 15mg/kg/dose every 4 hours
• Syrups comes in different strengths — always check the bottle
• If dose for weight is more than the dose for age — use the dose for age
• No more than 6 doses in 24 hours for first 2 days THEN 4 doses a day
• If child needs stronger pain relief — medical consult
• Suppositories can be used if adult or child can’t or won’t take oral paracetamol
• Come in 125mg, 250mg and 500mg strengths
• Use 1 or combination for right dose — Table 7.1
• If suppositories not available — paracetamol syrup can be given in rectum using lubricated 2mL syringe. Same dose as oral

* If 15kg or over — recommend to use smaller dose of stronger syrup

Oral non-steroidal anti-inflammatory drugs (NSAIDs)

Contraindications for NSAIDs 

• eGFR less than 60 or unknown
• Chronic kidney disease or heart failure AND taking diuretic and ACE inhibitor or ARB 
• Severe asthma
• High cardiovascular risk
• Stomach ulcers
• Severe bleeding, eg suspected ruptured organ
• If pregnant — medical consult before giving

Paracetamol-codeine (500mg+30mg)

Codeine (opioid) may make person drowsy, constipated — advise extra fluids and high fibre diet

• Do not use for children under 12 years
• Do not give more than maximum daily dose of paracetamol (paracetamol alone and/or paracetamol-codeine) in 24 hour period (adults 4g)

Opioids

Aim of opioid injection treatment is to stop severe pain as quickly as possible without sedating person — some discomfort may remain

Always have naloxone available when you give an opioid IV or SC  

Do first

Before giving opioids

• Medical consult — if this will cause serious delay in treatment may give morphine only THEN do medical consult as soon as possible
• Assess level of pain on a scale of 0 no pain to 10 worst ever pain
• Check patient’s sedation score 

Do

• Patient must be continuously monitored — repeat observations every 5 minutes for 15 minutes THEN every 15 minutes for 1 hour after last opioid dose given