Monday, April 26, 2010

Improvements in pain scoring

In modern medicine there are breakthroughs happening left and right on a daily basis. A new and improved pain scoring technique especially developed for emergent care provider, both pre-hospital and in an ED setting, will now help improve accuracy in pain management and will make the old 1 to 10 visual analogue scale superfluous.

Introducing the

CRAP Score - Cynical Real Alternative Pain Score

CRAP Score = (OPS+AF) x (SC)x (EC)

OPS = 10-point pain score (Old Pain Scale)
AF = Adjustment Factor (see below)
SC = Story Credibility
EC = Exam Credibility

For LPT (Low Pain Threshold) patients; calculate CRAP score:

  • If the patient reports their pain as being more than 10 on the conventional 10-point pain scale, subtract 1 point for every point over 10. If a patient claims their pain is 12, subtract 2 points and start with an 8.
  • For every visit the patient has had to your a&E in the past 12 months claiming a "chronic" or "undiagnosed" painful condition subtract 1 point.
  • Every time the patient says "ow" when you push on a non-painful or uninjured area of their body, subtract 1 point.
  • For every claimed allergy to a non-narcotic pain relief medication, subtract 1 point.
  • If they are wearing sunglasses/wrist-splints/neck-brace/insist on wheelchair/lying down, subtract 1 point.
  • If they have tape or ECG lead residue on their body from a prior hospital exam, subtract 2 points. (Waive the wheelchair/neck-brace penalty is the patient is registered with a disability)

For HPT (High Pain Threshold) patients, you add to their reported pain score:
  • If a spouse or family member forced them to come in, add 1.
  • If patient history shows that every A&E visit for a painful condition related to something torn, broken, ischaemic or perforated, add 2.
  • If they have no allergies add 1.
  • If they are tachycardic (racing heart) or hypertensive (high blood pressure) add 1.
  • If they have visible major injuries they may be in shock and won't feel the true pain till the endorphins wear off

Worked example 1
Young guy/gal goes to A&E for the 7th time in the past year for migraine (-6) reporting his headache as 12 on a 10 point scale (-2). He claims to be allergic to 5 over-the-counter pain meds (-5). He has been to A&E 5 times in the past year claiming other painful ailments e.g. back pain, belly pain, but tests found no disease or injury (-5). He is in the examination cubicle eating crisps/choccy and yelling into his mobile phone. He claims his migraine is a killer. When his abdomen is pressed he claims it is tender (-1), but he hadn't noticed due to the migraine being so bad.
CRAP score = (10 -6 -2 -5 -5 -1) x (0.5) x (1) = -4.5.
Even without Story Credibility of 0.5 and Exam Credibility of 1 that's a CRAP score of -9.

Worked example 2
Limping guy/gal is taken to A&E by spouse, but reports "fuss about nothing" and pain score of 4. Blood pressure and heartbeat are increased (+1). They've taken a couple of aspirin. Examination finds torn ankle ligaments, probable fractured tarsals plus fluid retention around ankle plus abrasions to forehead and forearms. Patient states s/he fell on icy pavement. Patient history over several years shows 3 previous visits for fractures/torn ligaments/open wounds requiring stitching.
OPS + AF = (4 +1 +1 +2) = 7
Even without a Story Credibility and Exam Credibility, that's a CRAP score of +8 and they've sustained real damage.


Found on Dragonqueen's Site, all credits go to her.

1 comment:

  1. Way to go!! A real live version that can be used effectively--where were you when I was triage nurse in a party town's ER!?

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