Page 128 Guide to Pain Management in Low-Resource Settings

116 O. Aisuodionoe-Shadrach

several assessment tools have been designed to objec- Although the multidimensional pain scale was
tively measure it. Pain has multiple dimensions with developed for pain research, it can be adapted for use in
several descriptions of its qualities, and its perception the clinic. An adapted version of the Brief Pain Invento-
can be subjectively modifi ed by past experiences. ry questions patients about pain location, intensity as it
Acute pain leads to a stress response consist- varies over time, past treatments, and the eff ect of pain
ing of increased blood pressure and heart rate, systemic on the patient’s mood, physical function, and ability to
vascular resistance, impaired immune function, and al- function in various life roles.
tered release of pituitary, neuroendocrine, and other
Is there an obligation to manage pain in the
hormones. Th is response could limit recovery from sur-
acute trauma and preoperative setting?
gery or injury. Adequate relief or prevention of pain fol-
lowing orthopedic surgery has been shown to improve Th e commitment to manage a patient’s pain and relieve
suff ering is the cornerstone of a health professional’s ob-
clinical outcomes, increase the likelihood of a return to
preinjury activity levels, and prevent the development of ligation. Th e benefi ts to the patient include shortened
hospital stay, early mobilization, and reduced hospital-
chronic pain. Undertreatment of acute pain can lead to
increased sensitivity to pain on subsequent occasions. ization cost.
Pain is not merely a clinical symptom but evi-
Furthermore, the sources of pain in acute trau-
ma and preoperative settings are mostly of deep somatic dence of an underlying pathology. In the acute trauma
and preoperative setting, there is a temptation to over-
and visceral origin, as may occur in road traffi c acci-
dents, falls, gunshot wounds, or acute appendicitis. Pain look pain and its specifi c management, while all eff orts
are geared toward treating the underlying pathology. Th e
in the acute trauma and preoperative settings is usually
caused by a combination of various stimuli: mechanical, challenge is to help the health professional realize that the
management of both symptoms (pain) and underlying
thermal, and chemical. Th ese stimuli cause the release
of nociceptive substances, e.g., histamine, bradykinin, pathology (acute appendicitis) should go hand in hand.
Using the WHO analgesic ladder, a rational systematic
serotonin, and substance P, which activate pain recep-
tors (nociceptors) to initiate pain signals. approach to pain management in the acute trauma and
preoperative setting can be developed and implemented.
How should pain be assessed?
Is pain an important issue to the patient who is
Because of its complex subjectivity, pain is diffi cult to in the acute trauma/preoperative setting?
quantify, making an accurate assessment problematic.
Yes. Freedom from pain can be considered a human
However, a number of assessment tools have been de-
right. As fanciful as that may seem, it must be empha-
veloped and standardized to identify the type of pain,
sized that pain is a natural accompaniment of acute
quantify the intensity of pain, and evaluate the eff ect
injury to tissues and is to be expected in the setting of
and measure the psychological impact of the pain a pa-
acute trauma. In such a scenario, the goal of the physi-
tient is experiencing.
cian is to ensure that the patient’s pain is tolerable.
A pain scale may be either one-dimensional or mul-
In a study conducted at an accident and emer-
tidimensional. In the acute trauma/preoperative setting,
gency room department of a university hospital in sub-
where the cause of pain is obvious and pain is expected
Saharan Africa, 77% of patients who had preoperative
to resolve more or less promptly, one-dimensional scales
analgesia considered the analgesic dosage inadequate,
are recommended. Examples include the following:
and 93% of those patients blamed this inadequacy of
• Numeric rating scale (NRS), in which the patient
pain relief on inadequate analgesic prescription by their
rates pain from 0 to 10 in increasing order of in-
doctors. Th e 77% of patients who had preoperative an-
tensity
algesia admitted they would have preferred a lot more
• Visual analogue scale (VAS), in which the patient
than what they were given.
marks the severity of pain on a line
• Verbal rating scale (VRS) What should the attitude of the attending
• Illustrative scales such as the Faces Pain Scale, physician be regarding the specifi c
which consists of drawings of facial expressions. management of pain in this scenario?
Th is type of scale is useful in children, the cogni- Concern. Often, paying attention to adequate analgesic
tively impaired, and persons with language barriers. coverage for this category of patients is overlooked in