- Assess and treat together. Acute pain management in the emergency department starts with listening, identifying dangerous causes and offering relief during the work-up. This checklist focuses on adults. Record pain severity, function and baseline observations; use an appropriate observational scale when self-report is unreliable. Agree on a functional goal, such as comfortable breathing or movement. EUSEM 2025 guidance.
- Match treatment to the mechanism. NSAIDs reduce prostaglandin-mediated inflammation; local anesthetics interrupt nerve conduction; opioids alter central pain processing but can depress ventilation. Combine appropriate approaches rather than repeatedly escalating one drug. Positioning, splinting and reassurance can reduce distress while medication takes effect.
- Nonopioids can be the main treatment. In a randomized trial of adults with acute extremity pain, ibuprofen plus acetaminophen showed no statistically significant difference in two-hour pain reduction versus three opioid–acetaminophen combinations. This single-dose study did not prove equivalence, assess adverse events or establish results for other painful conditions. Use it to support a nonopioid option, not to deny rescue analgesia. Chang et al., JAMA 2017.
- Check risks before prescribing. Review renal function, dehydration, gastrointestinal bleeding, heart failure, liver disease, pregnancy and other medicines. Use NSAIDs cautiously where renal, bleeding or cardiac risk is substantial; check total acetaminophen exposure, including combination products. AAEM guidance. Avoid routine NSAID use from 20 weeks of pregnancy; if necessary at 20–30 weeks, use the lowest effective dose briefly, and avoid at 30 weeks onward. FDA warning.
- Use opioids when benefits outweigh risks. Severe acute pain may need titrated IV opioids without exhausting nonopioids. Consider oral medication or protocol-based intranasal fentanyl when appropriate. Reassess sedation, ventilation, oxygenation and blood pressure after dosing. Frailty, sleep apnea, renal impairment and concurrent sedatives require particular caution. Keep airway support and naloxone available. Avoid long-acting preparations for new acute pain.
- Reassess the patient, not just the score. Review pain, function and adverse effects after each intervention, timed to its expected onset. Persistent or increasing pain warrants another examination and reconsideration of the diagnosis, route and treatment. Do not respond to new somnolence or deteriorating observations by simply increasing analgesia.
- Make discharge prescribing specific. If needed, use an immediate-release opioid in the smallest quantity matching the expected severe-pain period, with a nonopioid step-down and follow-up plan. Explain sedation, avoiding driving while impaired, alcohol and unapproved sedatives, safe storage and disposal; offer naloxone, especially with overdose risk. Give condition-specific return precautions. CDC guidance concerns adult outpatient prescribing, including ED discharge, and excludes sickle-cell pain, cancer-related pain, palliative and end-of-life care. CDC 2022 guideline.
- Analgesia does not replace diagnosis. Do not withhold indicated pain relief solely to preserve abdominal signs. Opioids can change examination findings, but randomized-trial evidence did not show a significant increase in management errors. The evidence cannot exclude a small increase in errors: document the examination and continue serial assessment and appropriate investigations. Ranji et al., JAMA 2006.
- For suspected renal colic, start with the recommended sequence. NICE recommends an NSAID first, IV acetaminophen if NSAIDs are contraindicated or insufficient, then an opioid if both are unsuitable or inadequate. Persistent pain, fever or systemic illness requires reassessment for complications; analgesia alone does not address an infected obstruction. NICE NG118.
- Chronic pain and opioid use disorder need individualized care. Look for a new acute cause before labeling pain a flare. Prioritize nonopioid measures and coordinate with the continuing prescriber when feasible; do not delay urgent care while waiting for contact. Suspected diversion and opioid use disorder are different assessments. Treat legitimate acute pain, offer evidence-based addiction care, and avoid abruptly stopping established opioid treatment unless a life-threatening problem, such as suspected overdose, requires intervention.
- Consider ketamine selectively. Sub-dissociative ketamine can be an alternative or adjunct for acute pain under local protocols. Explain possible unpleasant perceptual effects and use appropriate monitoring. Distinguish analgesia from procedural sedation.
- Use local or regional anesthesia when it fits the procedure. A well-chosen block can avoid repeated systemic analgesic doses. It requires suitable training, dose and formulation checks, monitoring, and readiness to treat local-anesthetic systemic toxicity. Account for additive toxicity when more than one local anesthetic is used. Lidocaine prescribing information.
- Infection can make local anesthesia less reliable. Tissue acidity changes drug ionization, but inflammation-related failure has several proposed mechanisms. Do not assume anesthesia is adequate because a dose was given: test its effect before starting and adjust the analgesic plan if inadequate. Mechanistic study and limitations.
Effective Acute Pain Management in Emergency Departments
Dr. Abdolghader Pakniyat
Effective Acute Pain Management in Emergency Departments
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