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INTRODUCTION

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Acute pain is the chief complaint for 75% to 80% of all ED visits. Procedural sedation and analgesia often is needed for painful interventions or diagnostic studies.

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CLINICAL FEATURES

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Responses to pain vary and may include increased heart rate, blood pressure, respiratory rate, and behavioral changes, however these responses may only have a mild correlation, so they cannot be relied upon exclusively. Pain is most objectively assessed with the use of several validated pain scales, though these scales may not be as accurate in elderly patients or trauma patients. Pain scales are a mainstay of assessing pain in young children.

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EMERGENCY DEPARTMENT CARE AND DISPOSITION

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During the primary assessment, determine the patient's perception of the degree of pain and continue to reassess their pain after any intervention. Be aware that children are vulnerable to oligoanalgesia for several reasons including difficulty assessing their pain and provider discomfort as well as unfamiliarity with medication dosing regimens.

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Pharmacologic and nonpharmacologic interventions may be helpful for treating anxiety and pain in the ED. Nonpharmacologic interventions include the application of heat or cold, immobilization and elevation of injured extremities, and distraction methods, such as feeding sucrose solution to infants. When pharmacologic intervention is needed, the selection of agent should be guided by the severity of pain necessitating analgesia, the route of delivery, and the desired duration of effects.

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Acute Pain Control

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Nonopioid Analgesics, such as acetaminophen, 650 to 1000 mg (15 mg/kg PO or PR in children) or nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, 400 to 800 mg PO (10 mg/kg PO in children) can be used to treat mild to moderate pain. Parenteral NSAIDs are no more effective than oral medications. Adverse effects of NSAIDS include gastrointestinal irritation, renal dysfunction, platelet dysfunction, and impaired coagulation. Furthermore, NSAIDs increase the risk of cardiac death in patients with ischemic heart disease. Aspirin should be avoided in children because of an association with Reye syndrome.

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Opiates, such as morphine, 0.1 mg/kg IV (0.1 to 0.2 mg/kg in children), fentanyl, 1 mg/kg IV (1 to 2 µg/kg in children), and hydromorphone, 0.015 mg/kg IV (0.015 to 0.020 mg/kg in children) are the agents of choice for moderate to severe pain. Children require more opiates proportionate to their weight than adults. The goal of therapy is to titrate the doses to effect. Side effects of opiates include respiratory depression, nausea and vomiting, confusion, pruritus, and urinary retention. Oral opioids may be tried as an alternative to parenteral administration, however they can have variable absorption and a slower effect.

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Special caution should be given to the use of codeine and tramadol. Codeine is not a reliable analgesic as up to 10% of the US population lack the necessary enzyme to convert it to its active state. Tramadol can produce ...

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