Acute pain management in emergency: EUSEM Guideline
Written By : Medha Baranwal
Medically Reviewed By : Dr. Kamal Kant Kohli
Published On 2021-01-03 14:30 GMT | Update On 2021-01-04 09:02 GMT
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The European Society for Emergency Medicine (EUSEM) has released clinical practice guidelines on acute pain management in emergency settings.
Mild to severe pain in the emergency department (ED) and in prehospital settings is subject to management with a wide range of analgesic agents.
Principles of Effective Pain Management
- Evaluate how distress is contributing to a patient's pain experience, take measures to address their pain empathically, acknowledging it and demonstrating a willingness to understand their experience.
- In all cases consider the use of non-pharmacological analgesic strategies to achieve pain relief. This may involve techniques such as splinting, immobilisation, heat/cold, distraction, etc. and for children additional distraction techniques such as play.
- If pharmacological analgesia is required, ensure that there are no contraindications to medications before administration and ensure that all medications administered are clearly documented.
- Analgesics should be administered orally where possible and, whatever route is used, titrated, if possible, until adequate pain management is achieved.
- Pain should be reassessed, and if analgesia is found to be inadequate stronger analgesics should be used, in conjunction with non-pharmacological methods.
Dosing Considerations for Adults
- Codeine: indicated for use in patients aged ≥12 years, in adults oral doses of 30–60 mg may be considered up to maximum adult dose of 240 mg/day which must not be exceeded.
- Fentanyl: for intranasal (IN) or IV administration dosing should be started at 50 μg if possible and may be repeated after initial dosing to a maximum dose of 200 μg or by continuous infusion according to local protocols; if IN fentanyl (50–100 μg) proves insufficient follow with IV fentanyl or IV morphine.
- Ketamine: indicated for use when opioids such as morphine or fentanyl prove insufficient or painful extrication from the emergency scene is required; IV dosing of 0.1 mg/Kg is recommended which can be repeated but not more frequently than 10 minutes, IN dosing of 0.7 mg/Kg can be considered with the potential to provide subsequent dosing of 0.3–0.5 mg/Kg at not more than 15 minutes or intramuscular (IM) dosing of 0.5–1 mg/Kg with the option to repeat dosing one.
- Metamizole: may be administered as an adjunct to paracetamol in moderate pain at an oral dose of 8–16 mg or slow IV infusion of 1 g, but the risks of serious adverse events mean it cannot be considered for first line treatment in severe pain.34,38 Serious adverse events include severe agranulocytosis, allergy and anaphylaxis, but its use may be beneficial in emergency care in hostile environments such as entrapment or inhospitable environments such as mountain rescue.
- Methoxyflurane: indicated for use in adult patients with moderate to severe acute trauma, one bottle of methoxyflurane in the Penthrox inhaler will provide up to 30 minutes analgesia with continuous use and longer with intermittent use.39 A second bottle may be added to the Penthrox inhaler if required for extended analgesia, further dosing is contraindicated within 24 hours.39 The use of methoxyflurane should be considered in inhospitable environments where patients are difficult to reach e.g. mountain rescue, entrapment or multiple casualties.
- Morphine: For IV administration at doses of 2–3 mg titrated with subsequent dosing not.
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