Induced pain is defined as short-lasting pain caused by the practitioner in predictable circumstances, potentially prevented by appropriate analgesia or sedation. Current literature regarding its optimal management is scarce. Our study sought to assess the reality of induced pain in emergency medicine.
Material and methods
We retrospectively analyzed the medical records of patients who attended our university emergency department in order to undergo one of the five following most frequent pain-inducing procedures: fracture reduction, dislocation reduction, abscess draining, thoracic drain placement, and external electrical cardioversion (EEC). Wound sutures and locoregional anesthesia were not considered. Physicians could refer to local protocols for both the abovementioned procedures and sedation. The frequency of events occurring in the five procedure groups was compared by means of a Chi-squared test.
In our study, 137 consecutive medical records were analyzed over a 3-month period (0.8 % of 17,000 admissions), corresponding to 1.5 induced-pain cases per day. The mean patient age was 47 years. Records concerned 48 abscess drains, 44 dislocation reductions, 30 fracture reductions, 12 thoracic drain placements, and 3 EECs. In total, 58 intravenous procedural sedations (42 %) were performed, involving 100% of EECs, 70 % of fracture reductions, 69 % of thoracic drain placements, 52 % of dislocation reductions, and 4 % of abscess draining procedures. The use of analgesia proved highly variable. Among the 79 patients who did not receive procedural sedation, 27 (34 %) were given intravenous analgesia, 13 (16 %) nitrous oxide and oxygen, 21 (26 %) oral analgesic medication, and 21 (26 %) no medical analgesia at all. Only four patients (3 %) were administered intravenous morphine. The probability for two random patients to receive exactly the same procedural sedation for a given pathology was 68.2 % for thoracic drain placements, 53.7 % for abscess drains, 15.9 % for dislocation reductions, and 3.4 % for fracture reductions. Although more serious conditions were treated with supplementary care, this variability in sedative and analgesic practices challenges both the quality of care and suitability of management procedures. However, only three adverse events occurred in the study population, representing 2 % of the procedures.
Conditions associated with induced pain represent the primary reasons for procedural sedation in the emergency room, accounting for 20 sedations per month. Significant differences (p <0.05) were observed between the five analyzed procedure groups, as well as in the use of sedation. For a same condition, analgesic and sedative support may range from intravenous sedation to the absence of any medication at all. Abscess drains and dislocation reductions illustrate this analgesia/sedation variability. This observation suggests that alternative approaches for potentially dangerous procedural sedations should be considered while being subject to clinical research. Regarding the insufficient use of morphine and heterogeneous implementation of local written procedures, practice improvements appear mandatory.
affiliations 1 Cliniques universitaires Saint-Luc, Service des Urgences, département de médecine aiguë, avenue Hippocrate 10, B-1200 Bruxelles