Acute Pain Management


Acute Pain Management, Emergency Department Pain Management, Acute Pain Control in the Emergency Department, Acute Pain Control, Opioid Use in the Emergency Department, Acute Severe Pain

  • Management
  • Acute Pain
  1. Treat new acute, painful conditions regardless of Opiate history while patient in the emergency department
    1. Examples: Long bone Fractures, Appendicitis, Renal Colic, Acute Cholecystitis
    2. Rapid control of acute symptoms in the emergency department
    3. Pain is considered an emergency condition by EMTALA
    4. Set reasonable expectations for Acute Pain Management (improved but not 100% resolved)
  2. Paranteral Opioid approach (if indicated)
    1. Control pain early with serial doses of Opioids and frequent reassessment
    2. Early definitive control of pain breaks the pain cycle
    3. Avoid under-treating with small, ineffective doses
  3. Consider Non-Opioid Analgesics and other measures
    1. See Below
  4. Use stepped approach to home Acute Pain Management
    1. See Oral Analgesic (for stepped Analgesic approach)
    2. Gear Oral Analgesic starting point based on response to acute pain medications in ED
    3. Use Acetaminophen and NSAIDs in combination (if not contraindicated)
      1. Common approach
        1. Acetaminophen 1000 mg orally every 6 hours AND
        2. Ibuprofen 400 to 600 mg orally every 6 to 8 hours
      2. Study used Ibuprofen 200 mg with Acetaminophen 500 mg
        1. Very effective for post-operative pain without the risks of Opioids
        2. Derry (2013) Cochrane Database Syst Rev (6):CD010210 +PMID:23794268 [PubMed]
    4. Consider adjunctive topical agents
      1. Diclofenac Gel
      2. Lidocaine Patch (4% patch is OTC and typically <$10 for 5 patches as of 2018)
      3. TENS unit
    5. Avoid Tramadol
      1. Equivalent to Non-Opioid Analgesics (but with increased Drug Interactions)
    6. Opioid management
      1. Prescribe a short course for 2-3 days of acute pain to allow for follow-up and re-evaluation (e.g. 8 tablets)
      2. Encourage to use other non-Opioid agents first, and limit Opioids to pain interfering with sleep
      3. Consider Morphine immediate release 10-30 mg orally every 4 hours prn adult moderate to severe pain
        1. Morphine IR 15 mg PO is equivalent to 5 mg IV
        2. Morphine IR is available in 15 mg and 30 mg tablets
        3. Morphine is less euphoric than Oxycodone and Hydrocodone
  5. Employ non-pharmacologic measures
    1. See Musculoskeletal Injury Management (e.g. RICE-M, Contrast Baths)
    2. Reduce provocative activities (e.g. crutch walking, work limitations)
    3. Avoid inactivity and maintain range of motion
    4. Consider physical therapy
  6. Short outpatient course of Acute Pain Management
    1. Close follow-up with primary care to reassess pain management
    2. Home Opioids (if indicated) should be limited to 3-7 days
      1. Counsel that prolonged Opioid use is a risk for dependence
  7. References
    1. (2015) Presc Lett 22(4)
    2. Birnbaumer (2013) Analgesia and Procedural Sedation, EM Bootcamp, CEME Lecture
  1. Typical parenteral Analgesics
    1. Ketorolac (Toradol) 10-15 mg IV
    2. Acetaminophen 1000 mg oral or IV (over 15 min)
  2. Novel Acute Pain Management strategies (use with caution only)
    1. Obtain Informed Consent and review dosing, adverse effects and risks prior to use
    2. Ketamine 0.2 mg/kg IV over 10 min, then 0.15 mg/kg/hour
    3. Lidocaine 2% at 1.5 to 2.5 mg/kg/h IV for 2-4 hours
    4. Clonidine 0.3 to 2 mcg/kg/h IV infusion
    5. Dexemedetomidine 0.2 to 0.3 mcg/kg/h IV infusion
  3. Acute Abdominal Pain
    1. Ketorolac (esp. for suspected Renal Colic)
    2. Ketamine (see above)
  4. Acute Headache
    1. IV crystalloid hydration (NS, LR) AND
    2. Ketorolac AND
    3. Diphenhydramine AND
    4. Prochlorperazine, Metoclopramide or Olanzapine
  5. Non-radicular back pain
    1. Ketorolac
    2. Trigger Point Injection
    3. Ketamine
    4. Lidocaine Patch
  6. Acute neuropathic pain or back pain
    1. Gabapentin (Neurontin) 300 mg orally
    2. Corticosteroid (Prednisone or Methylprednisolone)
    3. Typical and novel approaches as above
  7. Regional pain management
    1. Peripheral Nerve Block
  8. References
    1. Hipskind and Kamboj (2016) Crit Dec Emerg Med 30(10): 15-23
  • Evaluation
  • Determine if presenting complaint is an exacerbation of Chronic Pain
  1. Review medical record
    1. Medication refills (especially Opioids)
    2. Clinic and emergency department visits for painful conditions
  2. Review Prescription Drug Monitoring Programs (alliance of states sites)
  3. Determine if patient is in a pain program
    1. Review Controlled Substance Agreement
    2. Communicate with primary pain provider if available
      1. Alternatively, notify them that patient was seen for pain in Emergency Department
  4. Ask about Chemical Dependency and prescribed medication misuse
    1. Drug Diversion
    2. Chemical Dependency
    3. Recreational use of prescription medications
    4. History of prescription drug Overdose
  5. Be respectful
    1. Assess patients appropriately without immediately stereotyping or discounting their presenting symptoms
    2. Articulate to the patient what is doable for pain management (e.g. 30% reduction in pain, such as 6/10 to a 3-4/10)
  6. Discuss follow-up, alternatives and expectations
    1. Direct patients to follow-up within 1 week with primary care or pain management
    2. Patient should consider neuropathic pain medications (e.g. Gabapentin, Tricyclic Antidepressants, Duloxetine)
    3. Avoid Opioid doses above 50 mg/day Morphine equivalents for non-cancer Chronic Pain
    4. Opioid doses >90 mg/day Morphine equivalents for non-cancer, non-Palliative Care is a red flag
    5. Function that does not improve 30% on Chronic Opioids should be weaned (slowly, 10% every 1-2 weeks)
    6. (2016) Presc Lett 23(5): 25
  7. Informed Consent for Opioid Prescription
    1. See Opioid Prescription in Acute Pain
    2. Review goal of improved function (not complete pain elimination)
    3. Review short-term Opioid course
    4. Review risks of longterm tolerance, dependence and addiction with longer use
  1. Consider establishing an emergency department care plan for Chronic Pain patients
    1. Does not replace an outpatient pain management program or primary care provider management
    2. Creates a consistent plan of pain management across a group of emergency providers
    3. Reviews specific patient resources, contacts, and precautions in treating the patient's pain
  2. Review flare management
    1. See Chronic Pain Flare Management
  3. Patient not in pain program
    1. Discuss the problem with emergency department delivery of Chronic Pain Management
    2. Encourage close follow-up with primary care
    3. Encourage establishing with a pain management program
    4. Review that pain programs exist with better longterm outcomes
      1. Chronic Pain Management
      2. Chronic Narcotic Guideline
  • Resources
  • References
  1. Hipskind and Kamboj (2016) Crit Dec Emerg Med 30(10): 15-23
  2. Jaben in Herbert (2012) EM: Rap 12(9): 8