· Heart Rate—Heart rate is usually elevated when a patient has intolerable pain, but just like any other objective measure, other factors may also come into play. If a patient is on a beta blocker, the heart rate response to pain may be masked. In addition, if a patient is hypovolemic, hyperthyroid, hypercarbic or has a hyper-dynamic neuroendocrine disorder, the heart rate may be misleading.
· Blood Pressure—Blood pressure is usually elevated when a patient has intolerable pain. However, as with heart rate, other factors must be taken into consideration prior to attributing the elevated blood pressure to pain. In addition, all objective measurements should be compared to the patient’s pre-pain baseline. For example, if a patient had a baseline blood pressure of 160/90, then 160/90 would not be considered as an indication of acute pain with this individual.
· Pupil Size—It is an often-missed indicator of pain, however, pupil size may not only indicate severe pain, but also help guide narcotic de-escalation. For example, if a patient is in pain, there are increased circulating catecholamines from sympathetic stimulation. This leads to pupillary dilation. On the other hand, pinpoint pupils can indicate the central nervous system’s response to a therapeutic narcotic level. Can narcotics be titrated to pupil size? No, but pupil size can definitely be used as a guide in the treatment of acute pain.
Putting it all together
Our first approach in the assessment of acute pain is to observe with critical attention the objective indicators of pain: heart rate, blood pressure, respiratory rate and pupil size. If your evaluation shows a patient who is resting quietly in bed with a heart rate of 60, blood pressure of 120/80, respiratory rate of 12, what then is your initial impression prior to asking for the patient’s “feeling?”
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Based on the objective measures, I would maintain current analgesic levels. When asked, however, the patient does not respond how you would expect and rates their pain as intolerable. This is the dilemma facing healthcare providers on a daily basis and their resolution is to escalate analgesic therapy with opioids over 90% of the time.