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Acute pain

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute pain are prepared by our editorial team based on guidelines from the Eastern Association for the Surgery of Trauma (EAST/AOTA 2023), the Center for Disease Control (CDC 2022), the United States Department of Defense (DoD/VA 2022), the Academy of Orthopaedic Physical Therapy (AOPT 2021), the American Academy of Family ...
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Diagnostic investigations

Clinical examination: as per EUSEM 2020 guidelines, review observed signs of pain alongside patient self-reports, including HR, respiratory rate, facial expressions, or patient expressions of pain (such as groaning). Use these observations in conjunction with the patient's own evaluation, as alone those can under- or overestimate pain intensity.
B
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  • Assessment scales

Medical management

General principles
As per EUSEM 2020 guidelines:
Consider using multimodal analgesia, an approach involving the combination of opioid and non-opioid analgesics acting at different sites within the pain pathway to provide an additive or synergistic effect, to optimize outcomes in the treatment of patients with acute pain, reduce opioid-related side effects and prevent chronic pain.
C
Administer rapidly acting IV agents in small doses at frequent intervals until pain relief is achieved to allow the determination of the patient's individual requirements before long-acting medications or patient-controlled analgesia are initiated.
B

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  • Non-opioid analgesics (acetaminophen)

  • Non-opioid analgesics (NSAIDs)

  • Non-opioid analgesics (dipyrone)

  • Opioids

  • Ketamine

  • Inhaled analgesics (nitrous oxide)

  • Inhaled analgesics (methoxyfurane)

  • Other agents

Nonpharmacologic interventions

Attentional control: as per EUSEM 2020 guidelines, advise attention control methods including distraction techniques, concentration and focus on external stimuli using music, imagery, controlled breathing, breastfeeding for infants and play for adult and pediatric patients
B
. Recognize that virtual reality is emerging as a potential technique to occupy patients.
A

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  • Cold and heat therapy

  • Acupressure

Therapeutic procedures

Transcutaneous electrical nerve stimulation: as per EUSEM 2020 guidelines, recognize that transcutaneous electrical nerve stimulation has demonstrated evidence from postoperative settings that it can significantly reduce analgesic requirements.
A

Specific circumstances

Patients with fractures
As per AOTA/EAST 2023 guidelines:
Consider administering NSAIDs (such as ketorolac) for pain management in adult patients with a traumatic fracture.
C
Insufficient evidence to recommend the preferential use of either selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs.
I

Patient education

General counseling: as per EUSEM 2020 guidelines, be aware that it is important to patients that clinicians recognize their patients' pain, acknowledge it, in doing so validate the patient's situation, and if feasible to empathize with the patient.
B

Follow-up and surveillance

Monitoring of analgesia: as per EUSEM 2020 guidelines, reassess patients once analgesia has been provided, to ensure that their pain is being successfully managed, and reassess their pain relief regimen regularly during their stay in the emergency department.
B