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When: Pain should be assessed at its onset and reassessed frequently.
What You Need: Assessment of pain (based on history [see mnemonic below] and exam), reference list of
medications and related information (including side effects), availability of medications and delivery mechanisms
(needle, syringe, etc.).
What To Do:
- Assess patient’s pain using history and exam. This mnemonic will be helpful.
OPQRST Mnemonic for Pain Assessment
O = Onset - When did the pain start? Was it sudden or gradual?
P = Palliate/Provoke - What palliates or provokes the pain? What makes it better or worse?
Q = Quality - What does the pain feel like? (sharp, dull, tearing, etc.)
R = Radiate - Does the pain radiate? If so, from where to where?
S = Severity - How bad is the pain on a scale of 1 to 10? (with 1 being the least & 10 the most)
T = Time - How long have you been in pain? Is it continuous or intermittent? Has it gotten worse, better,
or stayed the same? - Consult reference material and use a stepped approach for the control of pain:
a. Mild to Moderate Pain: Begin, unless there is a contraindication, with a non-steroidal anti-inammatory
drug (NSAID) or acetaminophen. NSAIDs or single injections of local anesthetics alone may control mild to
moderate pain after relatively minor surgical procedures. NSAIDs decrease levels of inammatory mediators
generated at the site of tissue injury. At present, one NSAID (ketorolac) is approved by the Food and Drug
Administration for parenteral use. All but two NSAIDs (salsalate and choline magnesium trisalicylate) appear to
produce a risk of platelet dysfunction that may impair blood clotting and carry a small risk of gastrointestinal bleed-
ing. Acetaminophen does not affect platelet aggregation, but neither does it provide peripheral anti-inammatory
activity. Benzodiazepines (anti-anxiety drugs), other muscle relaxants and other classes of drugs are also used
for pain control due to their secondary effects.
b. Moderately Severe to Severe Pain: Normally treat initially with an opioid analgesic, especially for more
extensive surgical procedures that cause moderate to severe pain. The concurrent use of opioids and NSAIDs
often provides more effective analgesia than either of the drug classes alone. Even when insufcient alone to
control pain, NSAIDs or single injections of local anesthetics have a signicant opioid dose-sparing effect upon
postoperative pain and can be useful in reducing opioid dosages and side effects. Although it is likely that NSAIDs
also act within the central nervous system, in contrast to opioids, they do not cause sedation or respiratory
depression, nor do they interfere with bowel or bladder function.
c. Opioid Tolerance or Physiological Dependence: These complications are very unusual in short-term use by
opioid naive patients. Likewise, psychological dependence and addiction are extremely unlikely to develop when
patients without prior drug abuse histories use opioids for acute pain. Proper use of opioids involves selecting: 1)
appropriate drug, initial dose, and route and frequency of administration; 2) optimal drug/route/dose of non-opioid
analgesic, if desired; 3) acceptable incidence and severity of side effects; and 4) an inpatient or ambulatory
setting for pain management. Titrate opioids to achieve the desired therapeutic effect and to maintain that effect
over time.
d. Other Pain: When increasing doses of opioids are ineffective in controlling postoperative pain, search for
another source of pain, and consider other unusual diagnoses such as neuropathic pain (i.e., burning, tingling
or electrical shock sensation triggered by very light touch, and accompanied by a sensory decit in the area
innervated by the damaged nerve).
e. Other Therapies: Remember that interventions such as relaxation, distraction, and massage can reduce pain,
anxiety, and the amount of drugs needed for pain control. - Some analgesics available to the SOF medic are listed below.
a. Opioids:
Morphine - Indications: Moderate to severe pain (> 5 on 10 point scale). Example: Cardiac ischemia.
Contraindications: Relative: Untreated hypotension, mild COPD or asthma, full stomach; Absolute: allergy,
biliary disease, severe COPD or asthma. Route: IV preferred, IM, Oral (poorly absorbed); Dose: IV 2 to 4
mg then 2 mg every 10 to 15 minutes titrated to effect; IM 10 mg every 1 hour titrated to effect. Side
Effects: Respiratory depression, muscle relaxation, sedation, histamine release.