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\def\citeauthor{~Theresa~Florence~B,
              ~Kattepogu~Priyanka,
              ~Durfeshan~Eram,
              ~Hemalatha~R}
\def\citetitle{A Prospective Observational Study on Pain Management in Emergency Medicine}
\def\copyrightstmt{This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial- ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.}
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\begin{document}


\def\RunningAuthor{Hemalatha R et al.}
\firstPage{1}
\articleType{Original Article}
\receivedDate{03 Jan 2022}
\acceptedDate{19 Jan 2022}
\revisedDate{17 Jan 2022}
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\journalIssue{1}
\copyrightYear{2022}
\eISSN{2583-0953}
\journalDoi{10.26452/ijcpms.v2i1.243}
\def\authorCount{4}
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\def\journalTitle{International Journal of Clinical Pharmacokinetics and Medical Sciences}

\title{A Prospective Observational Study on Pain Management in Emergency Medicine}
\author{Theresa~Florence~B\textsuperscript{1}\textsuperscript{\href{https://orcid.org/0000-0002-2600-7425}{\XeTeXLinkBox{\includegraphics[height=7pt]{orcid-logo-pharmascope.pdf}}}},  
            Kattepogu~Priyanka\textsuperscript{1}\textsuperscript{\href{https://orcid.org/0000-0002-7422-4424}{\XeTeXLinkBox{\includegraphics[height=7pt]{orcid-logo-pharmascope.pdf}}}},  
            Durfeshan~Eram\textsuperscript{2}, 
            Hemalatha~R\textsuperscript{*}\textsuperscript{1}~\\[5pt]{\textsuperscript{1}Holy Mary Institute of Technology and Science, Bogaram village, Keesara Mandal, Medchal District-501301, Telangana, India}~\\{\textsuperscript{2}Department of Pharmacy Practice, Holy Mary Institute of Technology and Science, Bogaram village, Keesara Mandal, Medchal District-501301, Telangana, India}}

\begin{abstract}
Pain is a subjective, disagreeable, sensory, and emotional sensation that is linked with, or defined in terms of, actual or possible tissue injury. This performs biological roles, warning against an outside threat. It is essentially self-limiting upon removal or cure of the provoking source. Pain is one of the most common complaints of patients known to the hospital and accounts for nearly 80 percent of the reason for referral to the emergency department (ED). Paracetamol and diclofenac were more frequently advised drugs to patients. Tramadol, morphine, nicotine drugs were chosen by the emergency physician to treat severe pain. In our study, we had included 10 departments combining all analgesics prescribed from all the analgesic classifications. In our study, we have observed that mostly the route of administration of drugs was in the form intravenous mostly. Opioid analgesics and other opiate analgesics were prescribed according to the pain assessment. Paracetamol and diclofenac intravenous forms were mostly prescribed by the physician to treat mild and severe pain. The choice of drug for severe pain was injection morphine, fentanyl patch as well as injection, nicotine patch, injection tramadol was chosen. For the route of administration of analgesics, mostly the intravenous route was chosen as they are more effective in treating pain treat when compared with other routes of administration. In the observation of the study of 6 months, we had documented more cases from the orthopaedics department. In this study, the pharmacological aids employed for the management of pain in the study of people with varied pain intensities and conditions were able to prevent oligo-analgesia by the emergency physicians. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Pain,\newline Paracetamol,\newline Diclofenac,\newline Opioid Analgesics,\newline Oligo-Analgesia,\newline Emergency
\end{keywords}
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\makeatletter{\raggedright{\Large$^\ast$}Corresponding Author\par Name:\ Hemalatha~R~\\ Phone:\ +91 8985091531~\\  Email:\ Florencetheresa25@gmail.com
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        \makeatother
        
    
\section{Introduction}
Pain is a subjective, disagreeable, sensory, and emotional sensation that is linked with, or defined in terms of, actual or possible tissue injury. This performs biological roles, warning against an outside threat. It is essentially self-limiting upon removal or cure of the provoking source \unskip~\cite{1387018:24715942}.

\textbf{Types of Pain }

\textbf{Acute Pain}

Acute pain usually requires a determinable without pause cause to be decided. It is a biological perform that protects, acts as a warning that an external threat is noxious, or indicates organ malfunction \unskip~\cite{1387018:24715955}.

\textbf{Chronic Pain}

Often chronic pain is thought-about suffering that lasted more than six months. It does not mean a threat that needs immediate avoidance \unskip~\cite{1387018:24715955}. 

\textbf{Pathophysiology Includes}

\textbf{Pain Nociceptive}

Nociceptive pain, or Somatism - (arising from the skin, bone, joint, muscle or connective tissue arising) or Visceral {\textendash} (emerging from inside organs like large intestine). 

\textbf{Pathophysiologic Pain}

Pathophysiologic pain (e.g., diabetic neuropathy, fibromyalgia, postherpetic neuralgia, irritable bowel syndrome, recurrent headaches, and certain noncardiac chest pain) is typically described in terms of chronic pain. It results from nerve damage or irregular activity within the central nervous system or PNS. Pain circuits typically rewire themselves anatomically and biochemically \unskip~\cite{1387018:24715951,1387018:24715946}.

\textbf{Clinical Manifestations}


  
  \begin{enumerate}
  \item \relax Acute pain can be slow, burning, tingling, firing, radiating, erratic in severity, varied in location, and occurring with an apparent noxious stimulus during a temporary connection. 
  \item \relax Chronic pain develops frequently though rarely without a transient association with the nociceptive stimuli, the appearance of chronic pain can change (e.g., sharp to dull, clear to vague, for example) \unskip~\cite{1387018:24715952}. 
  \end{enumerate}
  \textbf{Pain Management in Emergency Medicine}

Emergency medicine is specially designed for the diagnosis and treatment of dull illness or injury. Medicine or emergency medicine (EM), also known as an accident and emergency department (A\&E), emergency room (ER), emergency ward (EW) or emergency department, may be a medical service centre specialized in emergency medicine, the emergency treatment of patients who are present without a prior appointment; either by themselves indicates this, or by an ambulance \unskip~\cite{1387018:24715941}. 

Addressing the patient's pain is the main foremost vital contributions to ED providers can make pain is the primary impetus for patients presentation to the emergency department its treatment is that acute medical care precedence. It was marked by deficiencies in every analysis and pain management. Enhancement within the pain assessment and management science has combined over the past decade to facilitate care improvements \unskip~\cite{1387018:24715953,1387018:24715949,1387018:24715956}.

\textbf{Assessment of Pain}

The following aspects ought to be elucidated while taking history: 


  
  \begin{enumerate}
  \item \relax The site, distribution, radiation from initial site 
  \item \relax Severity (subjective, and score on visual analog or another scale) 
  \item \relax Nature (dull, sharp, lancinating (stabbing), etc.) 
  \item \relax Mode of onset, duration of episodes, the time course of the problem. 
  \item \relax Aggravating and relieving factors 
  \item \relax Reduction in physical activity, especially leisure 
  \item \relax Medicines usage 
  \item \relax Response to previous therapy, analgesics used and effective dose 
  \item \relax Previous history of similar pain
  \item \relax Meaning of the pain to the patient, e.g. fear of malignancy
  \item \relax Concurrent diseases and treatment 
  \item \relax Absence from occupation 
  \item \relax Increased alcohol consumption
  \end{enumerate}
  By observation of pain behaviour, i.e. signs noted by a doctor or prescriber: 


  
  \begin{enumerate}
  \item \relax Grimacing, sighing, groaning, limping 
  \item \relax Guarding, i.e. touching, rubbing or holding affected area, muscular bracing of the affected area or reluctance to move it 
  \item \relax Posture 
  \item \relax Reactions on examination, e.g. reflex withdrawal, apparently exaggerated response 
  \item \relax Use of aids/supports
  \end{enumerate}
  \textbf{Pain Scales}

A pain scale measures a patient's pain intensity or other features. 

Pain scales are common communication tools in medical contexts and are used in a variety of medical settings. 

Pain scales are a necessity to assist with a better assessment of pain \unskip~\cite{1387018:24715957,1387018:24715954} and patient screening \unskip~\cite{1387018:24715944,1387018:24715943}. Pain scale types are tabulated in Table~\ref{tw-62bf6836576f}.


\begin{table*}[!htbp]
\caption{\boldmath {Types of Pain Scales} }
\label{tw-62bf6836576f}
\def\arraystretch{1.1}
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\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1176\linewidth-2\tabcolsep}p{\dimexpr.2546\linewidth-2\tabcolsep}p{\dimexpr.3778\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & Scale & Method & Comments\\
\tblmidrule 
1. &
  Adjective rating scale  &
  Patient measures pain by picking from an organized pain list descriptors, ranging from no pain to worst possible pain, with allowance for marks between discrete labels. &
  Easy to administer.\\
2. &
  Visual analog scale (VAS) &
  The patient places a mark that best describes pain severity over a linear scale of 10 cm, labelled at one end with a word such as no pain and the other end with the worst pain imaginable. &
  Pain level from the no-pain end measured in millimetres. A difference of 13mm is the smallest clinically meaningful improvement for pain management tends to be an average of 30 mm.\\
3. &
  Numeric rating scale &
  Patient with descriptors is asked to self-report pain on a scale of 0 to 10. &
  Usage of upheld fingers might be used in visual, auditory, or manual dexterity issues in patients. Not as racist as the VAS does.\\
4. &
  5-point global scale &
  Patient rates pain as 0 = none 1 = little 2 = some 3 = a lot 4= worst possible &
  A decrease of 1 point is a large change; scales with more choices allow monitoring of small changes in pain and may be more sensitive to changes.\\
5. &
  Verbal quantitative scale &
  The patient is asked to record pain self without descriptors on a scale of 0 to 10. &
  Scale most commonly used; easy to administer.\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Comparison of Pharmacologic Classes} }
\label{tw-33f757ca2df9}
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\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.09950000000000001\linewidth-2\tabcolsep}p{\dimexpr.1318\linewidth-2\tabcolsep}p{\dimexpr.23220000000000002\linewidth-2\tabcolsep}p{\dimexpr.19639999999999993\linewidth-2\tabcolsep}p{\dimexpr.3401\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & Class & Route of Administration & Advantages & Disadvantages\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.09950000000000001\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{1.}} &
  \multicolumn{1}{p{\dimexpr(.1318\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Non-steroidal anti-inflammatory drugs}} &
  PO &
  Mild/moderate somatic pain plus severe colicky pain &
  Use caution in the elderly and those with renal, GI, and hematologic disorders.\\
 &
   &
  Parenteral &
  Does not require GI absorption &
  No more effective than PO  \mbox{}\protect\newline More costly\\
\multicolumn{1}{p{\dimexpr(.09950000000000001\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{2.}} &
  \multicolumn{1}{p{\dimexpr(.1318\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{Opioids}} &
  IM &
  No IV access required &
  Painful injections Unreliable absorption\\
 &
   &
  PO &
  Can be effective if adequately dosed &
  Variable absorption, somewhat slower onset\\
 &
   &
  IV &
  Titrated dosing deal need IV link &
  Need for IV access\\
\multicolumn{1}{p{\dimexpr(.09950000000000001\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{3.}} &
  \multicolumn{1}{p{\dimexpr(.1318\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Local anesthetics}} &
  Incursion &
  Technical ease &
  Limited duration of therapy\\
 &
   &
  Peripheral nerve block &
  Opioid sparing &
  Technically difficult at some sites Facilitated with use of US guidance\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{\unskip~\cite{1387018:24715947}}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Gender Wise Distribution} }
\label{tw-7d34f2267ea3}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.33\linewidth-2\tabcolsep}p{\dimexpr.3547\linewidth-2\tabcolsep}p{\dimexpr.3153\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Gender   & \cAlignHack Number of Patients   & \cAlignHack Percentage (\%)  \\
\tblmidrule 
\cAlignHack Male   &
  \cAlignHack 64   &
  \cAlignHack 64\%  \\
\cAlignHack Female   &
  \cAlignHack 36   &
  \cAlignHack 36\%  \\
\cAlignHack Total   &
  \cAlignHack 100   &
  \cAlignHack \\
\cAlignHack Mean   &
  \cAlignHack 50.0   &
  \cAlignHack \\
\cAlignHack Standard deviation   &
  \cAlignHack 19.79   &
  \cAlignHack \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Department Based Distribution} }
\label{tw-8d099204582b}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3547\linewidth-2\tabcolsep}p{\dimexpr.3680000000000001\linewidth-2\tabcolsep}p{\dimexpr.2773\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Department   & \cAlignHack Number of Patients   & \cAlignHack Percentage (\%)  \\
\tblmidrule 
\cAlignHack Orthopedics   &
  \cAlignHack 52   &
  \cAlignHack 52\%  \\
\cAlignHack Gastroenterology   &
  \cAlignHack 14   &
  \cAlignHack 14\%  \\
\cAlignHack Neurology   &
  \cAlignHack 14   &
  \cAlignHack 14\%  \\
\cAlignHack Spine   &
  \cAlignHack 7   &
  \cAlignHack 7\%  \\
\cAlignHack General medicine   &
  \cAlignHack 4   &
  \cAlignHack 4\%  \\
\cAlignHack Urology   &
  \cAlignHack 2   &
  \cAlignHack 2\%  \\
\cAlignHack Pulmonology   &
  \cAlignHack 3   &
  \cAlignHack 3\%  \\
\cAlignHack Plastic surgery   &
  \cAlignHack 2   &
  \cAlignHack 2\%  \\
\cAlignHack Nephrology   &
  \cAlignHack 1   &
  \cAlignHack 1\%  \\
\cAlignHack Endocrinology   &
  \cAlignHack 1   &
  \cAlignHack 1\%  \\
\cAlignHack Total   &
  \cAlignHack 100   &
  \cAlignHack \\
\cAlignHack Mean   &
  \cAlignHack 10.0   &
  \cAlignHack \\
\cAlignHack Standard deviation   &
  \cAlignHack 15.56   &
  \cAlignHack \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Distribution Based on Plan of Management} }
\label{tw-71c991074996}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.33519999999999996\linewidth-2\tabcolsep}p{\dimexpr.2163\linewidth-2\tabcolsep}p{\dimexpr.2298\linewidth-2\tabcolsep}p{\dimexpr.2187\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Departments   & \multicolumn{2}{p{\dimexpr(.4461\linewidth-2\tabcolsep)}}{\cAlignHack Plan of management  } & \cAlignHack P-value  \\
\rowcolor{kwdboxcolor}\cAlignHack  & \cAlignHack Surgical & \cAlignHack Medical & \cAlignHack \\
\tblmidrule 
\cAlignHack Orthopedics   &
  \cAlignHack 52   &
  \cAlignHack 2   &
  \multicolumn{1}{p{\dimexpr(.2187\linewidth-2\tabcolsep)}}{\multirow{9}{\linewidth}{\cAlignHack 0.037  }}\\
\cAlignHack Gastroenterology   &
  \cAlignHack 6   &
  \cAlignHack 9   &
  \\
\cAlignHack Spine   &
  \cAlignHack 2   &
  \cAlignHack 3   &
  \\
\cAlignHack Endocrinology   &
  \cAlignHack 0   &
  \cAlignHack 1   &
  \\
\cAlignHack Plastic surgery   &
  \cAlignHack 2   &
  \cAlignHack 0   &
  \\
\cAlignHack Pulmonology   &
  \cAlignHack 0   &
  \cAlignHack 3   &
  \\
\cAlignHack Urology   &
  \cAlignHack 1   &
  \cAlignHack 1   &
  \\
\cAlignHack General medicine   &
  \cAlignHack 0   &
  \cAlignHack 4   &
  \\
\cAlignHack neurology   &
  \cAlignHack 1   &
  \cAlignHack 13   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Distribution of Medication Based on Gender} }
\label{tw-f0e34b4af4e4}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.407\linewidth-2\tabcolsep}p{\dimexpr.21410000000000004\linewidth-2\tabcolsep}p{\dimexpr.2006\linewidth-2\tabcolsep}p{\dimexpr.17830000000000002\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Medication   & \cAlignHack Female   & \cAlignHack Male   & \cAlignHack P-value  \\
\tblmidrule 
\cAlignHack Paracetamol   &
  \cAlignHack 23   &
  \cAlignHack 52   &
  \multicolumn{1}{p{\dimexpr(.17830000000000002\linewidth-2\tabcolsep)}}{\multirow{8}{\linewidth}{\cAlignHack 0.54  }}\\
\cAlignHack Diclofenac   &
  \cAlignHack 9   &
  \cAlignHack 16   &
  \\
\cAlignHack Tramadol   &
  \cAlignHack 5   &
  \cAlignHack 18   &
  \\
\cAlignHack Fentanyl   &
  \cAlignHack 3   &
  \cAlignHack 13   &
  \\
\cAlignHack Buprenorphine   &
  \cAlignHack 4   &
  \cAlignHack 0   &
  \\
\cAlignHack Nicotine   &
  \cAlignHack 0   &
  \cAlignHack 2   &
  \\
\cAlignHack Morphine   &
  \cAlignHack 0   &
  \cAlignHack 1   &
  \\
\cAlignHack Hyoscine butyl bromide   &
  \cAlignHack 2   &
  \cAlignHack 0   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Distribution Based on Classification of Drugs} }
\label{tw-63f6bd742029}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.51339999999999996\linewidth-2\tabcolsep}p{\dimexpr.48660000000000004\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Classifications & \cAlignHack Number of Patients\\
\tblmidrule 
\cAlignHack Non-opioids  &
  \cAlignHack 75 \\
\cAlignHack Opioid analgesics  &
  \cAlignHack 42 \\
\cAlignHack Opioid agonist and antagonist  &
  \cAlignHack 4 \\
\cAlignHack NSAIDs  &
  \cAlignHack 25 \\
\cAlignHack Opiate analgesics  &
  \cAlignHack 1 \\
\cAlignHack Anti-spasmodics  &
  \cAlignHack 2 \\
\cAlignHack Total  &
  \cAlignHack 149 \\
\cAlignHack Mean  &
  \cAlignHack 24.83 \\
\cAlignHack Standard deviation  &
  \cAlignHack 29.44 \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/ec5aa3e5-97b4-496e-8c19-98fede836621-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/ec5aa3e5-97b4-496e-8c19-98fede836621-upicture1.png}{\includegraphics{images/ec5aa3e5-97b4-496e-8c19-98fede836621-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Age Based Distribution}}
\label{f-8bf0cf4a8039}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/c3f3d918-65ac-467a-9d22-986a98b2748a-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/c3f3d918-65ac-467a-9d22-986a98b2748a-upicture2.png}{\includegraphics{images/c3f3d918-65ac-467a-9d22-986a98b2748a-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Pain Score Based Distribution}}
\label{f-f490a20592d5}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/d783a25b-ff4b-47aa-8909-0610ad7009b7-upicture3.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/d783a25b-ff4b-47aa-8909-0610ad7009b7-upicture3.png}{\includegraphics{images/d783a25b-ff4b-47aa-8909-0610ad7009b7-upicture3.png}}{}
\makeatother 
\caption{\boldmath {Distribution of Medication based on the Pain Score}}
\label{f-34f46b0e6865}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/2a72c2bc-b7ec-4285-84af-40939ac10325-upicture4.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/2a72c2bc-b7ec-4285-84af-40939ac10325-upicture4.png}{\includegraphics{images/2a72c2bc-b7ec-4285-84af-40939ac10325-upicture4.png}}{}
\makeatother 
\caption{\boldmath {Distribution of Medication Based on Age}}
\label{f-70d9339519c0}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/6c19c4ca-bdf4-4abc-a630-38a82517cc56-upicture5.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/6c19c4ca-bdf4-4abc-a630-38a82517cc56-upicture5.png}{\includegraphics{images/6c19c4ca-bdf4-4abc-a630-38a82517cc56-upicture5.png}}{}
\makeatother 
\caption{\boldmath {Distribution Based on Dosage Forms}}
\label{f-e11618dd2f1e}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/fe45f8d2-cdc7-4c0e-9ca3-f0229348b9f6-upicture6.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/fe45f8d2-cdc7-4c0e-9ca3-f0229348b9f6-upicture6.png}{\includegraphics{images/fe45f8d2-cdc7-4c0e-9ca3-f0229348b9f6-upicture6.png}}{}
\makeatother 
\caption{\boldmath {Distribution Based on Dose Variation}}
\label{f-693afeb2fb9d}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/2835dc68-0a43-4b55-9506-04dc8aa52a04-upicture7.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/2835dc68-0a43-4b55-9506-04dc8aa52a04-upicture7.png}{\includegraphics{images/2835dc68-0a43-4b55-9506-04dc8aa52a04-upicture7.png}}{}
\makeatother 
\caption{\boldmath {Distribution Based on Combination of Classifications}}
\label{f-99979bba719b}
\end{figure}
\egroup
\textbf{Pain Treatment (Pharmacological) }

There are different classes of drugs available to treat pain pharmacologically. Class of drugs, ROA, Advantages \& Disadvantages are tabulated in Table~\ref{tw-33f757ca2df9}.

The administration of pharmacological agents is the basic component of acute pain control. "The key to effective pharmacological pain management in ED is a selection of a pain intensity suitable agent and it is time for analgesic action, ease of administration, safety, and efficacy". Anxiety and feelings of lack of control are generally followed by intense pain. If verbal reassurance in conjunction with an analgesic is not enough, instead an anxiolytic can be useful \unskip~\cite{1387018:24715950,1387018:24715948,1387018:24715945}.

\textbf{Aim}

A prospective observational study on pain management in emergency medicine.

\textbf{Objectives}
  
  \begin{enumerate}
  \item \relax To understand the prevention of oligoanalgesia. 
  \item \relax Know the side effects and risks of the strategies for treating acute pain, including its prevention and treatment. 
  \item \relax Understand the assessment of pain and function. 
  \item \relax To determine the pattern of treatment in emergency cases of acute pain. 
  \item \relax To evaluate the events contributing to oligoanalgesia.
  \end{enumerate}
  
    
\section{METHODOLOGY}
In this observational study methodology is as follows: 

\textbf{Study Site}

The prospective observational study is on treating pain in Emergency Medicine was performed at Sunshine Hospitals, Secunderabad, a tertiary care hospital. 

\textbf{Study Period}

The study was conducted for 6 months.

\textbf{Study Design}

This design of this study is a prospective observational study.

\textbf{Inclusion Criteria}


  
  \begin{enumerate}
  \item \relax Patients aged between 13 -90 years. 
  \item \relax Patients who are suffering from mild to severe pain (pain score 2 - 10).
  \end{enumerate}
  \textbf{Exclusion Criteria}


  
  \begin{enumerate}
  \item \relax Patients who do not wish to consent to this.
  \item \relax Pregnant and lactating women. 
  \item \relax Infants.
  \end{enumerate}
  \textbf{Source of Collection of Data}

\textbf{Data Collection Form}

It contains patient demographic details like age, gender, weight, check-in date, discharge date, medical history, medication history, pain score, physical examination, provisional diagnosis, laboratory findings, investigations, STAT medications, conformational diagnosis, plan of care, drug treatment chart, progress chart and advice on discharge.

\textbf{Statistical Analysis}

Descriptive statistics and Graphical presentation of our project ``A Prospective Observational Study on Pain Management in Emergency Medicine'' values are expressed as frequency, percentage, mean and standard deviation. In the analysis performed the P -value, 0.05 is considered as no significant variation.
    
\section{RESULTS}
During the period of study, a total of 100 patients were enrolled in this hospital, in which 64 (64\%) were males and 36 (36 percent) were female. Gender wise distribution given in Table~\ref{tw-7d34f2267ea3}. The more number of patients 19 (19\%) were distributed among the age group 6069 years, and the least being 1 patient among the age group 90-99 years. Age based distribution was represented in Figure~\ref{f-8bf0cf4a8039}.

The more no of patients 52 (52\%) belonged to the department of orthopaedics and the lowest number of patients 1 (1\%) each belonged to departments of nephrology and endocrinology. Department based distribution was given in Table~\ref{tw-8d099204582b}.

The highest number of patients 34 (34\%) were admitted with pain scoring 4 which is moderate and the lowest number of patients 1 (1\%) were admitted with pain scoring 10 which is severe. Pain score based distribution was represented in Figure~\ref{f-f490a20592d5}.

Department of orthopedics has chosen surgical management as its plan of care for most of their patients 52 (52\%), and the department of neurology has chosen medical management as its plan of care for most of their patients 13 (13\%). P-value was found to be 0.037 and the null hypothesis is accepted. Distribution based on plan of management was given in Table~\ref{tw-71c991074996}. Paracetamol was prescribed more often in patients with mild and moderate pain scores, while tramadol was the most prescribed medication in patients with severe pain. Distribution of medication based on the pain score was given in Figure~\ref{f-34f46b0e6865}. Paracetamol was the most prescribed medication in both males and females. P-value was found to be 0.54 ((P\textgreater\ 0.05) hence, there is no significant variation. Distribution of medication based on gender and age given in Table~\ref{tw-f0e34b4af4e4}  \& Figure~\ref{f-70d9339519c0}  respectively. Non-opioids were highly prescribed classification of drugs for the management of pain and the less prescribed classification of drugs were opiate analgesics. Distribution based on Classification of Drugs given in Table~\ref{tw-63f6bd742029}. The intravenous route was mostly used route of administration as they're more effective in treating pain when compared to other routes of administration. Distribution based on Dosage forms were given in Figure~\ref{f-e11618dd2f1e}.

This distribution is based on the various doses of medications used. Distribution based on dose variation given in Figure~\ref{f-693afeb2fb9d}. Distribution based on combination of classifications given in Figure~\ref{f-99979bba719b}. P-value was found to be 0.067 (P\textgreater\ 0.05) hence, there is no significant variation.
    
\section{DISCUSSION}
The largest percentage of patients category between 60 {\textendash} 69 which means 19 percent among hundred patient and the lowest number of patients was between 90-99 is one percent. In the study population of 100, 36\% of the population were female and 64\% were male. From the study population, when pain assessment was done, most of the patients were assessed with pain score 4 which is moderate and least being pain score 10 which is severe. An assessment of pain and understanding of the physical and psychological condition of the patient is an important consideration to treat pain. 

In the study conducted, the orthopedic department has the highest number of study population being 52\%. Department of orthopedics also has the highest number of patients with severe, moderate, and mild pain scores. In this study we have observed that the most prescribed drug was acetaminophen both in male and female, followed by diclofenac which is also the most prescribed drug by the emergency physician.

Non-opioid drugs are the most often used classification of drugs irrespective of pain score, followed by opioid drugs that are used for patients with pain intensity ranging from moderate to severe. As we have already mentioned that acetaminophen is the most frequently prescribed drug among other drugs, it is mostly given intravenously with a dose of 1gm. Diclofenac is frequently prescribed with the 75mg dose IV. 

In most of the study population, emergency physicians chose a single classification of a drug to treat pain 53\%, followed by including two different classifications in the treatment 35\%. Patients with moderate to severe pain tramadol were most prescribed drug 50mg IV route 58. This study, we have included 10 different departments were included and the percentage of the population in each department is orthopedics 52\%, gastroenterology 14\%, neurology 14\%, spine 7\%, general medicine 4\%, pulmonology 3\%, urology 2\%, plastic surgery 2\%, nephrology 1\% and endocrinology 1\%.

The percentage of analgesics used in different departments are orthopaedics 54\%, gastroenterology 15\%, neurology 14\%, spine 5\%, general medicine 4\%, urology 2\%, pulmonology 3\%, plastic surgery 2\%, nephrology 1\% and endocrinology 1\%. More number of analgesics were prescribed to the study population belonging to the age group between 40 -49 years (42\%), followed by (30\%) to the age group between 20 -39 years, then to the age group between 60-69 years (28\%), to the age group between 20 -29 years (24\%), then to the age group 50-59 years (23\%), then to the age group between 70 -79 years (8\%), then to the age group between 80 -89 years (7\%), then to the age group between 0-19 years (5\%), and then to the age group between 90 -99 years (1\%). 

Based on the primary and secondary objectives of the study pain was assessed with a numerical rating scale (NRS) is employed. Based on the assessment pain is classified into mild, moderate, severe, or worst imaginable pain. For mild pain non-opioid or NSAIDs have been advised, for moderate non-opioids along with opioids or sometimes opioid alone is advised, and for severe pain opioids along with opioid agonist antagonists, and narcotic drugs are advised, and when it comes to worst pain imaginable opiate along with other classes of drugs are advised.
    
\section{CONCLUSION}
Pain is one of the most common complaints of patients known to the hospital and accounts for nearly 80 percent of the reason for referral to the emergency department (ED). Paracetamol and diclofenac were more frequently advised drugs to patients. Tramadol, morphine, nicotine drugs were chosen by the emergency physician to treat severe pain. In our study, we had included 10 departments combining all analgesics prescribed from all the analgesic classifications. In our study, we have observed that mostly the route of administration of drugs was in the form intravenous mostly. Opioid analgesics and other opiate analgesics were prescribed according to the pain assessment. Paracetamol and diclofenac intravenous forms were mostly prescribed by the physician to treat mild and severe pain. The choice of drug for severe pain was injection morphine, fentanyl patch as well as injection, nicotine patch, injection tramadol was chosen. For the route of administration of analgesics, mostly the intravenous route was chosen as they are more effective in treating pain treat when compared with other routes of administration. In the observation of the study of 6 months, we had documented more cases from the orthopaedics department. In this study, the pharmacological aids employed for the management of pain in the study of people with varied pain intensities and conditions were able to prevent oligo-analgesia by the emergency physicians.

\textbf{Ethical Considerations}

We obtained the informed consent from every patient.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that there is no conflict of interest.
    
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