Pain Management Summary

Key Principles

  • Start analgesia at triage
  • Don't delay due to unclear diagnosis
  • Moderate/severe pain: analgesia within 15 minutes
  • Monitor and reassess regularly

Analgesia Types

  • Paracetamol: 1g qds (oral/IV)
  • NSAIDs: Ibuprofen, Naproxen, Diclofenac
  • Opiates: Codeine, Morphine
  • Entonox: Short-term severe pain

Pain Scale Management

  • Mild (1-3): Oral paracetamol/NSAID
  • Moderate (4-6): Add oral codeine
  • Severe (7-10): IV opiates + other analgesics

Time Targets

  • Initial assessment: Within 15 minutes
  • Mild pain review: 60 minutes
  • Moderate pain review: 30 minutes
  • Severe pain review: 15 minutes

Special Populations

  • Elderly: Paracetamol first-line, caution with NSAIDs/opiates
  • Pregnancy: Paracetamol safe, avoid NSAIDs
  • Asthma: Avoid NSAIDs if bronchospasm

Key Precautions

  • Check previous paracetamol use
  • NSAIDs: GI, renal, CV risks
  • Opiates: Airway/respiratory depression
  • Document all analgesia

Pain Management in Emergency Department

Comprehensive guide to recognition, assessment, and treatment of pain

Introduction

Recognition and alleviation of pain should be a priority when treating the ill and injured. This process should start at triage, be monitored during their time in the ED and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge.

Key Principle: When patients first present to the ED the diagnosis may be unclear and it is important that the lack of diagnosis does not delay administration of appropriate analgesia.

Time Target: All emergency departments should ensure patients with moderate and severe pain receive adequate analgesia within 15 minutes of arrival.

Types of Analgesia

Paracetamol

Administration

  • Available as oral, rectal and intravenous preparations
  • Standard oral and IV dose for adults is 1 g qds
  • IV dose adjusted for patients < 50 kg

Clinical Use

  • IV route useful when NBM and rapid mild-moderate analgesia required
  • Rectal preparation best avoided in adults (variable/slow absorption)
  • Check previous paracetamol use before prescribing

NSAIDs

Common NSAIDs

  • Ibuprofen: 400 mg PO tds - fewer side effects, good analgesic
  • Naproxen: 500mg PO initially then 250 mg every 6-8 hrs
  • Diclofenac: 50 mg PO tds, 100mg PR - useful for renal colic

Precautions

  • Avoid in asthmatics with NSAID-induced bronchospasm
  • Avoid in peptic ulcer disease
  • Use with caution in elderly and women with fertility issues
  • Avoid in pregnancy, particularly third trimester

Diclofenac Warning: Increased risk of thrombotic events (MI) and C. difficile. Contraindicated in IHD, PVD, CVD and heart failure.

Opiates

Codeine

  • Available as oral and IM preparations
  • 30-60 mg qds typical adult doses
  • Lower doses in elderly
  • More effective when combined with paracetamol

Morphine

  • Available as oral, IV and IM preparations
  • 0.1-0.2mg/kg IV typical adult dose
  • Titrate to desired response
  • Oral route not recommended for acute pain in ED

Antiemetics: Routine prescription with opiates not recommended. Only required if patient already experiencing nausea/vomiting.

Entonox

Use and Administration

  • 50% mixture of nitrous oxide and oxygen
  • Useful for short-term relief of severe pain
  • Helpful for short uncomfortable procedures

Contraindications

  • Head injuries
  • Chest injuries
  • Suspected bowel obstruction
  • Middle ear disease
  • Early pregnancy
  • B12 or folate deficiency

Entonox should not be viewed as definitive analgesia. Ensure rapid assessment and institution of appropriate analgesia when used as sole source.

Pain Assessment

Pain assessment forms an integral part of the National Triage Scale. Multiple assessment tools are in use. The experience of the member of staff triaging will help in estimating the severity of the pain.

Assessment of pain in the ED is often not as good as it could be which is particularly concerning since pain is often the reason for attending.

Benefits of Adequate Pain Assessment

Departments are encouraged to formalise pain recording in the same manner as the regular documentation of vital signs.

Pain Management Protocol

Pain Level Analgesia Initial Assessment Review
No Pain (0) No action Within 15 minutes of arrival Within 60 minutes of initial assessment
Mild Pain (1-3) Oral paracetamol OR oral NSAID Within 15 minutes of arrival Within 60 minutes of initial assessment
Moderate Pain (4-6) As for mild pain, PLUS oral NSAID (if not already given) OR oral codeine phosphate Within 15 minutes of arrival Within 30 minutes of initial assessment
Severe Pain (7-10) IV opiates OR rectal NSAIDs PLUS oral analgesics Within 15 minutes of arrival Within 15 minutes of initial assessment

Non-pharmacological techniques: In all cases, consider using measures such as applying a dressing, immobilising a limb, or other appropriate interventions to achieve analgesia.

Reassessment: Following reassessment if analgesia is still inadequate, use stronger/increased dose of analgesics along with non-pharmacological measures.

Special Populations

Elderly Patients

  • Paracetamol: Safe first-line with good safety profile
  • NSAIDs: Use with caution at lowest possible dose
  • Opiates: Appropriate dose reduction required
  • Consider GI, renal, CV side effects and drug interactions
  • Anticipate CNS interactions increasing respiratory depression risk

Pregnancy

  • General rule: Try to avoid any medication
  • Paracetamol: Safe in all three trimesters
  • Ibuprofen: Best avoided, only in second trimester if essential
  • Morphine/Codeine: Can be used in all trimesters if necessary
  • Delivery: Avoid opiates during delivery

Asthma Patients

  • Avoid NSAIDs in patients with known NSAID-induced bronchospasm
  • Paracetamol generally safe alternative
  • Opiates can be used with appropriate monitoring
  • Consider non-pharmacological methods where possible

Clinical Pearls

Condition-Specific Analgesia

  • Angina: Nitrates particularly effective
  • Renal colic: Diclofenac PR effective
  • Musculoskeletal: NSAIDs with good anti-inflammatory properties
  • Severe trauma: IV opiates preferred

Documentation & Monitoring

  • Document pain scores regularly
  • Record all analgesia administered
  • Monitor for side effects, especially with opiates
  • Reassess pain after interventions

Discharge Planning

  • Ensure adequate analgesia at discharge
  • Provide appropriate follow-up if needed
  • Educate patients about medication use
  • Consider non-pharmacological advice