Approach to Pain

The approach to non-traumatic chest pain requires early recognition of life threatening conditions.  Patients with life threatening conditions may have stable initial vital signs. 

For a patient presenting with chest pain, the following are the list of differential diagnoses 

• Acute coronary syndrome 
• Cardiac tamponade 
• Pericarditis 
• Pulmonary embolism 
• Tension pneumothorax 
• Acute  chest  syndrome  (sickle  cell patients) 
• Lung infection (pneumonia) 
• Esophageal perforation 
• Reflux Esophagitis 
• Musculoskeletal pain 

Investigations 

Depending on the clinical presentation, the following investigations maybe required: POC  ECG,  Bedside  USS-(cardiac,  lungs,  pleural,  IVC,  Abdominal  aorta,  kidneys  etc),Serum  electrolytes,  POC  Troponin,  Blood  gases,  Serum  creatinine  and  urea,  Urine  pregnancy  test,  Radiological investigations- Chest X-ray and/or CT scan- chest. 

Pharmacological Treatments 

Treat the underlying cause as indicated in specific chapters. The following analgesia may be used to  relieve the pain: 

A: paracetamol (PO) 1g6hourly for 24hrs 

OR 

A: ibuprofen (PO )400mg 8hourly for 24hours 

OR 

A: diclofenac (IM) 50-100mg stat  

For those patients who are unable to take oral medications 

B: tramadol (IV) 50-100mg stat 

OR 

C: morphine (IV) 0.1mg/kg stat 

OR 

D: paracetamol (IV) 1g stat 

If myocardial ischemia is highly suspected give:  

A: acetylsalicylic acid (PO)325mg stat  

AND  

D: clopidrogel (PO) 300mg stat 

Referral: Refer to higher facility with expertise when failed to establish the cause of the chest pain. 

Abdominal  pain  is  among  the  common  complaints  of  patients  presenting  to  the  Emergency  Department. While majority have benign and self-limited etiology, the goal is to identify those with  serious or life threatening etiologies so as to perform early intervention. 

Differential Diagnoses: 
Surgical causes: 

• Abdominal aortic aneurysm 
• Mesenteric ischemia 
• Perforation (PUD, bowel, esophagus, appendix) 
• Intestinal obstruction 
• Upper GI bleeding 
• Lower GI bleeding
• Splenic rupture
• Acute appendicitis
• Pancreatitis
• Gallbladder diseases

Genito-urinary causes 

• Ectopic pregnancy 
• Torsion (Testicular, ovarian) 
• Dysmenorrhoea 
• Endometriosis 
• Ureteric and kidney stones 
• Urinary tract infection 
• Pelvic inflammatory disease 

Medical causes 

• Myocardial infarction 
• Peptic ulcer disease 
• Gastro esophageal reflux disease 
• Inflammatory bowel syndrome 
• Gastritis 
• Hepatitis

Investigations 

Depending on the clinical presentation, the following investigations may be required: ECG,  Bedside  USS-  (gall  bladder,  liver,  lungs,  IVC,  Abdominal  aorta,  kidneys  etc),  Serum  electrolytes,  Troponin,  Blood  gases,  Lactate,  Serum  Creatinine  and  Urea,  Urine  pregnancy  test,  Radiological investigations (Chest and Abdomen X-ray and/or CT scan- Abdomen). 

Pharmacological Treatments 

For pain control, the following analgesia maybe used: 

A: paracetamol (PO)1g 6hourly for 24hours  

OR 

A: diclofenac (IM) 50-100mg stat. 

OR 

A: hyoscine butyl bromide (PO) 10mg 8hourly for 24 hours 

For those patients who are unable to take oral medications 

B: tramadol (IV) 50-100mg stat 
OR 

C: morphine (IV) 0.1mg/kg stat 

OR 

B: hyoscine butyl bromide (IM) 10mg stat 

OR 

D: paracetamol (IV) 1g stat 

Approach to acute headache 

Headache  is  a  challenging  complain  as  it  requires  balancing  symptomatic  control  with  rapid  assessment  for  life  threatening  diagnoses.  Headaches  can  be  categorized  into  primary  and  secondary.  Primary  causes  are  neurologic  and  include:  tension,  cluster  and  migraine.  Secondary  headaches are as a results of an underlying pathological process such as malignancies, infections  and other organic causes. 

Differential diagnoses 

Sudden onset severe headache 

• Subarachnoid hemorrhage 
• Cerebral venous thrombosis 
• Hypertension emergency 
• Adrenal and pituitary emergencies 
• Hypoglycemia 
• Fever 
• Meningitis 
• Malaria 
• Brain abscess 

Investigations 

Will be specific basing on the clinical presentation of the patient. These may include: 

• Malaria test 
• Random blood glucose test  
• Blood Gases 
• POC Urine dipstick  
• Urinalysis 
• CSF analysis 
• POC ECG 

Pharmacological Treatment 

A:  paracetamol  (PO):  Adult  1g  8hourly  for  3days; Paediatrics  15mg/kg  6hourly  when required to a maximum of 4doses per 24hours 

OR 

A:  ibuprofen  (PO):  Adult  400mg  8hourly  for  3days; Paediatics 5-10mg/kg  8hourly  for  24hours 

For severe pain or if the patient is unable to take orally, IV/ IM analgesia administration may be  administered. These includes: 

For those patients who are unable to take oral medications 

B: tramadol (IV) 50-100mg stat 
C: morphine (IV) 0.1mg/kg stat 
D: paracetamol (IV) 1g stat 

Other pains may include: 

• Generalized body ache
• Joint pain
• Pain due to local infections
• Pains due to injury
• Eye pains
• Ear pains

Non-pharmacological and Pharmacological Treatments 

Perform the primary and secondary assessment with interventions when needed. 

For  generalized  pain  give  analgesics,  advise  the  patient  to  rest  and  make  a  follow-up.  For  joint,  infections, injury, eye and ear pains treat as for main disease. 

CAUTION! 

• Do not use acetlysalicylic acid for abdominal pain or if a patient is vomiting or has nausea and do not use acetlysalicylic acid in children below 12years. Patients with peptic ulcers should not be given acetlysalicylic acid tablets.
• Refer the patients when pain persists despite of medication given for pain relief for further investigation.

Referral:  

Refer patients if: 

• Children with moderate and acute severe pain
• No response to oral pain control
• Uncertain diagnosis
• All acute abdominal pain accompanied by vomiting and no passing of stool
• Pain requiring definitive treatment for the underlying disease
• Pain requiring opioids