THE USE OF ANALGESICS IN PATIENTS WITH ACUTE ABDOMINAL PAIN

LoVecchio, F., et al, J Emerg Med 15(6):775, 1997

BACKGROUND: Analgesics in patients with acute abdominal pain are often withheld for fear that they may change physical examination findings and thus may be unsafe.

METHODS: We conducted a randomized, prospective, placebo-controlled trial to investigate changes in physical examination following the administration of placebo, 5 mg, or 10 mg of morphine to 49 patients with acute abdominal pain.

RESULTS: One patient was withdrawn secondary to inadequate documentation. Of the 48 patients who completed the trial, a statistically significant change in physical examination was noted in both groups receiving analgesics, but not in the placebo group. No adverse events or delays in diagnosis were attributed to the administration of analgesics.

CONCLUSION: We conclude that physical examination does change after the administration of analgesics in patients with acute abdominal pain and that a larger study is needed to evaluate analgesic safety in this subpopulation of emergency department patients.

INTRAVENOUS MORPHINE FOR EARLY PAIN RELIEF IN PATIENTS WITH ACUTE ABDOMINAL PAIN

Pace, S., et al, Acad Emerg Med 3(12):1086, December 1996

OBJECTIVE: To determine whether morphine affects evaluation or outcome for patients with acute abdominal pain.

METHODS: Prospective, double-blind, placebo-controlled administration of morphine sulfate (MS) or normal saline (NS) in the setting of acute abdominal pain. The study was performed at a military ED with an annual census of 60,000 visits. Patients > or = 18 years old who had abdominal pain for < or = 48 hours were included. Patients who were allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded. The physicians indicated a provisional diagnosis, a differential diagnosis, and a provisional disposition. Study solution was titrated to the patient's assessment of adequate analgesia (up to a volume equivalent of 20 mg of MS); pain response was monitored using a visual analog scale (VAS). The patients were followed until diagnosis occurred or symptoms resolved.

RESULTS: Of 75 patients enrolled, 71 completed the study; 35 patients received MS and 36 received NS. More than half (44; 62%) of the patients were admitted from the ED; 28 patients underwent surgery. The VAS pain level improved more for the MS group, 3.9 +/- 2.8 cm, than it did for the NS group, 0.8 +/- 1.5 cm (p < 0.01). Study solution dose was less in the MS group than it was in the NS group, 1.5 +/- 0.5 mL vs 1.8 +/- 0.4 mL (p < 0.01). There was no difference between the groups when comparing accuracy of provisional or differential diagnosis with that of final diagnosis. Differences between provisional and actual dispositions were the same in all groups. There were 3 diagnostic or management errors in each group.

CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients.

A RANDOMIZED CLINICAL TRIAL OF ANALGESIA IN CHILDREN WITH ACUTE ABDOMINAL PAIN.

Kim MK, Strait RT, Sato TT, Hennes HM. Acad Emerg Med 2002 Apr(4):281-7.

OBJECTIVE: To evaluate the effects of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain.

METHODS: A randomized, double-blind, placebo-controlled clinical trial was conducted at an emergency department of a tertiary care children's hospital. Children aged 5-18 years with abdominal pain of < or =5 days' duration, pain score > or =5 on a 0-10 visual analog scale, and need for surgical evaluation were eligible. Following the initial assessment, patients were randomized to receive either 0.1 mg/kg morphine or an equal volume of saline. The pediatric emergency medicine physician and surgical consultant independently recorded the areas of tenderness to palpation and percussion, and their diagnoses before the study medication and 15 to 30 minutes later.

RESULTS: Sixty patients were enrolled, and 29 received morphine and 31 received saline. The demographic characteristics between the two groups were similar. The median reduction of pain score between the two study groups was 2 (95% CI = 1 to 4; p = 0.002). There was no significant change in the areas of tenderness in both study groups. Children with surgical conditions had persistent tenderness to palpation and/or percussion. There was no significant change in the diagnostic accuracy between the study groups and between the physician groups. All patients requiring laparotomy were identified and no significant complication was noted in the morphine group.

CONCLUSIONS: Intravenous morphine provides significant pain reduction to children with acute abdominal pain without adversely affecting the examination, and morphine does not affect the ability to identify children with surgical conditions.

COMMENTS: As these studies have demonstrated, it is no longer acceptable to withhold pain medications in the evaluation of patients with abdominal pain.