You have a new patient!
A 57-year-old woman with a PMH of peptic ulcer disease presents to the emergency department 20 minutes after slipping and falling while out for a jog. She twisted her left ankle awkwardly while stepping off the pavement and fell to the side. She did not hit her head. She got up after the fall but has not tried to put weight on the ankle. Her vital signs are stable. She has a temperature of 37°C, a heart rate of 110 beats per minute, respirations at 18 breaths per minute, a blood pressure of 128/60, and an oxygen saturation of 96% on room air.
She is currently seated in a chair and appears uncomfortable. On exam, the left ankle appears more swollen than the right, with no bruising. She has tenderness to palpation at the posterior edge of the left lateral malleolus but no left midfoot tenderness. The right foot is non-tender. Pulses are intact throughout with a 2-sec capillary refill distally. She states, “Please help me; I can’t take the pain!”
Introduction
Pain is one of the most common reasons patients seek care in the ED. Pain is a signal from the body to alert the patients of actual or potential tissue damage. Addressing pain is a key part of the emergency department practice. However, doing so appropriately requires understanding our options to treat pain and a clear process to assess the factors causing the patient’s pain [1]. Pain treatment offers numerous advantages, such as alleviating pain-induced tachycardia in specific cases like acute MI and aortic dissection. Additionally, improved pain relief contributes to higher patient satisfaction.
Pain Assessment
When administering analgesics to patients in pain, there are no definitive contraindications. However, several factors should be considered when selecting the appropriate analgesic agent, including its route and dose. These factors encompass the pain’s intensity, probable cause, and the patient’s age, weight, medical history (including comorbidities and drug allergies), and vital signs. Pain is a complex and subjective experience that is unique to each patient. Appropriately assessing pain requires a thorough history and physical exam that include:
- Location: Where is the pain? Does it travel or go anywhere else?
- Onset: When did the pain begin? Is this an acute, chronic, or exacerbation of a chronic issue?
- Provocation: What makes the pain worse?
- Palliation: Does anything make this pain feel better? What has the patient tried to make it feel better, even if it didn’t work? Has the patient taken any medication at home to help with this, and what was the impact? If this patient has had this pain before, what made it better last time?
- Quality: How does the pain feel?
- Radiation: Does the pain go to any other location?
- Severity: How severe is the pain? Can they compare it to other experiences they’ve had? How does it limit their activities, such as movement, eating, and sleeping?
- Timing: Is the pain constant, or does it come and go? Does it change severity or quality over time?
Pain intensity scale
- Numerical ranking: Ask your patient to rank the severity from 0 to 10, with 0 being no pain at all and 10 being the worst pain possible.
- Verbal descriptors: Use descriptions from the patient of the pain and its impact on their functionality to rank their pain.
- Visual descriptors: Use visual cues from your patient to rank their pain. The most common of these scales is the Wong-Baker scale, which is commonly used in children or nonverbal patients.
It is also important to remember that patients in pain may become agitated or mentally altered due to their pain. Severe pain in one area of the body may mask other symptoms or signs the patient is experiencing; hence, it is crucial to re-examine these patients after analgesia.
Analgesics
In the emergency department, treatment plans are often tailored to moderate/severe and acute and/or chronic pain.
Severe Acute Pain
In the management of moderate to severe acute pain, parenteral opioids are the primary treatment choice. These opioids target specific receptors in the central and peripheral nervous systems, altering how painful stimuli are perceived and responded to. Initially, they are administered as a bolus dose based on the patient’s weight, followed by titration every 5-15 minutes after reassessment. Opioids provide excellent analgesia, but they come with a long list of side effects that can be detrimental to the patient, even in the acute pain setting. Nausea and respiratory depression are the most significant side effects of all opioids, albeit with varying degrees. Parenteral opioids can also trigger pruritus and/or urticaria due to mast cell destabilization. Medications such as antiemetics, antihistamines, and naloxone can help reverse these potential side effects. Morphine is often the preferred parenteral opioid, with fentanyl and hydromorphone serving as alternatives. A safe initial dose of morphine is 0.1 mg/kg administered intravenously, while subcutaneous administration can be used if IV access is not available (although it is more painful and slower in onset). Please refer to the complete list of opioids and their recommended initial dosing regimens provided below.
- Fentanyl: 0.25-1 µg/kg IV push [2], Short-acting opioid q. 15-60 minutes for severe pain.
- Hydromorphone: 0.015 mg/kg IV/SC [3], q. 2-4 hours, avoid large doses in naive patients.
- Oxycodone: 0.05-0.15 mg/kg PO [4], q. 3-4 hours.
- Morphine: 0.1 mg/kg IV/SC [5], q. 3-4 hours, may cause release of histamine.
- Oxycodone/Acetaminophen: 5-10 mg oxycodone/325-650 mg acetaminophen PO [6], q. 4-8 hours, moderate or severe pain (max dose of acetaminophen 4,000 mg/day).
- Hydrocodone/Acetaminophen: 5 mg hydrocodone/325 mg acetaminophen, 1 to 2 tablets PO [7], q. 4-8 hours, moderate or severe pain (max dose of acetaminophen 4,000 mg/day).
Moderate Acute Pain
In cases of mild to moderate pain, oral opioids provide a suitable choice after initial non-opioid analgesia. Among these options are oxycodone combined with acetaminophen or hydromorphone combined with acetaminophen to impose a maximum daily dosage. The recommended dose for the opioid component is 0.05-0.15 mg/kg, and it can be repeated every 4-6 hours. Refer to the full list of opioids and their initial dosing regimens above.
However, the primary recommendation for moderate acute pain is non-opioid analgesics like NSAIDs and acetaminophen. They can synergistically complement opioids, potentially reducing the overall required dose of medications and minimizing the likelihood of side effects.
Acetaminophen is the safest option among these analgesics, accessible in oral and intravenous forms. While its exact mechanism remains uncertain, it exerts its effects centrally. NSAIDs, such as ibuprofen and ketorolac, inhibit cyclooxygenase (COX), thereby blocking prostaglandin-mediated inflammation. However, inhibiting prostaglandin synthesis leads to renal vasoconstriction and thus should be avoided in those with kidney disease. Please refer to the complete list of non-opioids and their recommended initial dosing regimens provided below.
- Acetaminophen: 10-15 mg/kg PO/IV [8], Avoid if taking other acetaminophen-containing drugs or in patients with liver failure.
- Ibuprofen: 5-10 mg/kg PO [9], Avoid in elderly patients and those with renal disease and peptic ulcer disease.
- Ketorolac: 0.5 mg/kg IV/IM [10], Should only be given q6 hours, No more than 5 days.
Chronic Pain
It is important to recognize that patients with conditions that cause chronic pain or recurrent episodes of severe pain, such as sickle cell, have frequent or even chronic usage of opioid medications that require an individualized pain management plan. While chronic pain is challenging to address in the ED setting, these patients frequently get undertreated for their acute exacerbations [11]. Chronic pain is treated similarly to acute pain, using opioids for severe pain and non-opioids for more moderate pain. Treatment depends on the severity and previous history of analgesic success [12]. A step ladder approach, including non-opioid and opioid therapy, will be appropriate as part of departmental guidelines.
In addition, patients with a past or current history of a substance use disorder, including opioid use disorder, can still present with real, severe pain that may require the use of opioids for management. It is essential to assess these patients carefully and treat their pain like any other patient. If there are concerns that the patient’s condition may be related to a substance use disorder, it may be appropriate to refer them to a multidisciplinary specialist for support. This should be done after conducting a thorough history and physical examination and addressing immediate medical needs [13]. It is also vital that the ED team sticks to an individualized pain management plan once made by a multidisciplinary team on every recurrent presentation.
When making decisions for your patient, it is crucial to prioritize awareness of the addictive nature of opiates. To aid in this challenging choice, assess the patient’s opioid tolerance, history of substance abuse, and the risk associated with prescribing short-term PRN opioids upon discharge. The NIH Opioid Risk Tool (ORT) is helpful for screening for opioid abuse risk [14].
Local Anesthesia
Local anesthetics obstruct pain signal transmission by temporarily obstructing sodium channels in sensory nerve membranes. In the emergency department, lidocaine is commonly used, with or without epinephrine, to enhance hemostasis and prolong anesthetic efficacy. Bupivacaine, a longer-acting agent, is typically employed for regional anesthesia. While local anesthetics are generally safe, systemic CNS and cardiovascular toxicity can occur at large doses. Traditional teaching states that local anesthetic administration should be avoided in end organs such as the ears, nose, and penis to prevent ischemia. However, strong evidence is lacking to support this concern [15]. Local departmental or hospital guidelines should be followed in this case.
- Lidocaine:
- Dose: Nerve Block 5-300 mg (maximum 4 mg/kg or 300 mg),
- Acute Pain (Patch) 4%-5% patch q24 hours.
- Rapid onset. The maximum dose of lidocaine is 4 mg/kg (without epinephrine) and 7 mg/kg with epinephrine [16,17].
- Lidocaine is safe in pregnancy and breastfeeding.
- Dose: Nerve Block 5-300 mg (maximum 4 mg/kg or 300 mg),
- Bupivacaine:
- Dose: Max dose 2.5 mg/kg, 3 mg/kg with epinephrine [18].
- Slower onset and higher risk of cardiovascular toxicity.
- Chloroprocaine:
- Dose: Max dose 10 mg/kg, 15 mg/kg with epinephrine [19].
- Used in the case of allergy to lidocaine and other amide local anesthetics.
Procedural Sedation
Procedural sedation refers to the administration of medications aimed at reducing anxiety and pain while enhancing tolerance to a particular medical procedure. This technique is reserved for hemodynamically stable patients who are expected to be able to maintain their airways throughout the procedure. Common indications of this technique include cardioversion, orthopedic reductions, and other painful procedures [20]
A common approach to procedural sedation:
- Risk stratification to prepare for potentially difficult airway management
- Use the Mallampati Score to assess the difficulty of the airway should the patient lose their airway during the procedure. Refer to UpToDate Mallampati Airway Classification.
- Determine the ASA Score category. Refer to the ASA Physical Status Classification System.
- Informed Consent
- Typically, it is required before the procedure to discuss the complications and alternative options.
- Gathering Supplies
- IV, O2, Monitoring including capnography.
- BVM and airway trolley
- Assemble Team
- Depending on the complexity of the procedures, decide about the team members and their roles. A separate person should typically be responsible for sedation and airway monitoring while one or two other members perform the procedure. For details about team dynamics, refer to this book’s chapter on Teamwork.
- Perform the procedural sedation
- Administer procedural sedation medications (See below)
- Perform the procedure while constantly assessing hemodynamic stability and respiratory status.
- Post Sedation Care
- Provide post-sedation monitoring and reassessment, and then discharge instructions according to the individual case and departmental guidelines.
Most Common Procedural Sedation Medications
- Midazolam:
- Dose: 0.1 to 0.5 mg/kg IV [21].
- Comments: No analgesic effect, administered before the procedure to reduce anxiety and provide amnesia.
- Fentanyl:
- Dose: 1 mcg/kg IV [22].
- Comments: Reduces pain, commonly used in reductions and I&D as an adjunct to other medications or local anesthesia.
- Propofol:
- Dose: 0.5-1 mg/kg IV [23].
- Comments: Used as a general short-acting anesthetic and causes respiratory depression and hypotension.
- Etomidate:
- Dose: 0.15 mg/kg IV [24].
- Comments: Used as a general anesthetic; can cause myoclonus.
- Ketamine:
- Dose: 1-2 mg/kg IV [25], 2-4 mg/kg IM (especially in pediatrics).
- Comments: The dissociative anesthetic that provides both amnesia and analgesia. Known to cause aggressive emergence reaction and rarely laryngospasm.
Hints and Pitfalls
Like all treatments, it is crucial to reassess the patient after giving them medication and understand how medication can change your ability to evaluate the patient. A patient in severe pain may be unable to provide a full history or participate in a complete physical exam until their pain has been controlled. For example, a patient with an extremely painful angulated fracture of the humerus may not be able to participate in an exam to evaluate their distal neurovascular status, or the same patient may have such severe pain in their arm that they do not notice that they are also having abdominal pain. Treating pain earlier in such encounters can help facilitate high-quality patient care.
Factors that can lead to undertreatment include atypical presentation, communication barriers, and implicit bias. Pediatric patients, patients with neurocognitive disorders, and patients from different cultural or linguistic backgrounds are frequently undertreated for their pain.
Special Patient Groups
It is essential to carefully evaluate pain in patients who cannot directly communicate with the physician [26].
Those patients may be:
- Nonverbal at baseline
- Speak a different language than the physician
- Have a cognitive impairment
- Geriatric patients
- Underreporting of pain
- Higher frequency of illness-causing cognitive impairment and communication barriers such as Alzheimer’s
- Concerns for side-effects
Geriatric patients generally have poor physiological reserve and polypharmacy. While these factors need to be considered in the choice of analgesics, their dosage, and required monitoring, these concerns should not lead to undertreatment of pain in this population.
Revisiting Your Patient
How should we manage our 57-year-old female with peptic ulcer disease, who presented with a twisted ankle? Given that her left ankle is swollen and that she has bony 9/10 tenderness at the posterior edge of the left lateral malleolus but no left mid-foot pain, it is likely that she has an uncomplicated closed ankle fracture.
The initial step in management would be to start treating her pain soon after her presentation. An important KPI (Key Performance Indicator) in this regard is that the degree of pain is assessed on arrival in every patient who presents to ED with pain, and individually planned titrated analgesia is started as early as possible.
Given that she is in acute, moderately severe pain with a history of peptic ulcer disease (PUD), she would most likely benefit from a drug like Oral Hydromorphone and Oral/IV Paracetamol. In this patient’s case, NSAIDs, such as Ibuprofen, should specifically be avoided due to her history of PUD. Initial pain management in the emergency department can also be managed with “RICE,” which includes rest, ice, compression, and elevation of the injured body part. The RICE technique is an effective way to alleviate pain in patients who deny pain medication or who are still waiting to see a provider. It is important to reassess pain and vital signs after administering analgesics.
If this patient had an evident ankle deformity with weak pulses, she would have required procedural sedation and urgent reduction.
Authors
Kayla Peña
Rutgers Robert Wood Johnson Medical School
Kelsey Thompson
UCLA Harbor
Munawar Farooq
College of Medicine and Health Sciences, UAEU Al Ain, UAE
Listen to the chapter
References
- Hachimi-Idrissi S, Coffey F, Hautz WE, et al. Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment. Intern Emerg Med. 2020;15(7):1125-1139. doi:10.1007/s11739-020-02477-
- In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Oxycodone/Acetaminophen: Drug Information. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Hydrocodone/Acetaminophen: Drug Information. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Paracetamol: In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Dora-Laskey, A. (2022). Acute Pain Control. Society for Academic Emergency Medicine (SAEM M3 Curriculum). Retrieved from https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m3-curriculum/group-acute-pain-control/acute-pain-control.
- Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: A Systematic Review and Meta-analysis. JAMA. 2018;320(23):2448-2460. doi:10.1001/jama.2018.18472
- Nordt SP, Ray L. Lidocaine. In: Mattu A and Swadron S, ed. ComPendium. Burbank, CA: CorePendium, LLC. Updated May 12, 2023. Accessed May 13, 2023.https://www.emrap.org/corependium/drug/recUEl2x9lfeYKbws/Lidocaine#h.tuo0od96 muij.
- Perry JS, Stoll KE, Allen AD, Hahn JC, Ostrum RF. The opioid risk tool correlates with increased postsurgical opioid use among patients with orthopedic trauma. Orthopedics. 2023;46(4):e219-e222. doi:10.3928/01477447-20230207-04
- Schnabl SM, Herrmann N, Wilder D, Breuninger H, Häfner HM. Clinical results for use of local anesthesia with epinephrine in the penile nerve block. J Dtsch Dermatol Ges. 2014; Apr;12(4):332-339. doi: 10.1111/ddg.12287. Epub 2014 Mar 3. PMID: 24581175.
- In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Lidocaine with epinephrine. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Miner James R., Paetow Glenn. Procedural Sedation. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: ComPendium, LLC. https://www.emrap.org/corependium/chapter/recCvtWt5In5h4fLJ/Procedural-Sedation#h.9du7441ga4gn. Updated September 15, 2021. Accessed May 13, 2023.
- Midazolam. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Fentanyl. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Propofol. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Etomidate. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Ketamine. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
- Tagliafico L, Maizza G, Ottaviani S, et al. Pain in non-communicative older adults beyond dementia: a narrative review. Front Med (Lausanne). 2024;11:1393367. PublishedAugust 15, 2024. doi:10.3389/fmed.2024.1393367
FOAM and Further Reading
Pediatric pain: Pediatric Pain Management
Chronic pain: I CAN’T GET NO SATISFACTION FOR MY CHRONIC NON-CANCER PAIN
Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
