Guideline sources The following summarized guidelines for the evaluation and management of acute pain are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2022), the United States Department of Defense (DoD/VA 2022), and the European Society for Emergency Medicine (EUSEM 2020). 1 2 3 4 Calculator Calculator Calculator FLACC Scale for assessment of FLACC R Scale for assessment Pain asses Guidelines 1. Diagnostic investigations Clinical examination: 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 https://web.pathway.md/diseases/recDXw6lDrVx6e4eb 1/5 6/23/23, 2:02 AM Acute pain Pathway observations in conjunction with the patient's own evaluation, as alone those can under- or overestimate pain intensity. B Assessment scales: use a patient self-reporting scale that works within the clinical environment and with the patient's ability. A Show 6 more 2. Medical management General principles: 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 Non-opioid analgesics (paracetamol): Recognize that pain management with PO paracetamol in patients with acute blunt minor musculoskeletal extremity trauma, B traumatic or inflammatory pain to the extremities when used in combination with codeine, B acute musculoskeletal pain, B and pain caused by ankle sprain B is at least as effective as with NSAIDs; and IV paracetamol has similar analgesic effects to IV morphine in patients with isolated limb trauma. B Recognize that both PO and IV formulations of paracetamol provide significant pain reduction at 30 minutes when used in the emergency department. B Non-opioid analgesics (nonsteroidal anti-inflammatory drugs): recognize that NSAIDs such as ibuprofen, diclofenac, ketoprofen and naproxen are commonly used in both the pre-hospital and emergency department settings for mild-to-moderate pain, particularly with an inflammatory component, and are most commonly administered PO, IV or topically; they remain the preferred analgesic in renal colic, with observed equivalence to opioid or opioid-paracetamol combined analgesia at 30 minutes B , and effective analgesia in fracture. B Show 3 more Non-opioid analgesics (dipyrone): recognize that dipyrone is used differently across Europe, rare in some and widely used in others. Recognize that its use is limited due to its association with life-threatening blood disorders such as agranulocytosis, which are thought to have a possible association with patient ethnicity, and so its use must be weighed against these risks. Recognize that it can be administered PO, IV or subcutaneous and has demonstrated efficacy in patients with renal colic, acute pain due to pancreatitis B , and primary headache - episodic tension-type headache. A Opioids: As per CDC 2022 guidelines, consider initiating opioid therapy for acute if the benefits are anticipated to outweigh the risks to the patient and only after maximization of nonpharmacologic https://web.pathway.md/diseases/recDXw6lDrVx6e4eb 2/5 6/23/23, 2:02 AM Acute pain Pathway and nonopioid pharmacologic therapies. Discuss the realistic benefits and known risks of opioid therapy with patients before prescribing opioid therapy for acute pain. C Show 4 more As per VA 2022 guidelines: Consider screening for pain catastrophizing and co-occurring behavioral health conditions in patients with acute pain when considering opioid therapy, to identify patients at higher risk for negative outcomes as these conditions are associated with a higher risk of harm. C Do not prescribe long-acting opioids for acute pain. D Ketamine: Recognize that ketamine: is administered IV, intramuscular or intranasal provides analgesia at sub-dissociative doses is as effective as morphine, which may be opioid sparing, and with a faster onset of action a number of studies have been carried out which support its use. B Show 2 more Inhaled analgesics (nitrous oxide): recognize that nitrous oxide has demonstrated significant analgesia of NRS 3 at 15 minutes, B and sustained significant reductions in pain scores at 20 minutes associated with high levels of patient and nurse satisfaction in pre-hospital and emergency department settings. B Inhaled analgesics (methoxyfurane): recognize that methoxyfurane has been suggested to be effective and well-tolerated in patients with trauma and visceral pain, with a rapid onset of analgesia, B but in visceral pain overall analgesia was lower than that seen with fentanyl. Recognize that methoxyfurane has been suggested to be effective for analgesia in the majority of pediatric patients but was less effective than morphine and fentanyl in terms of reducing pain score by 30% overall. B 3. Nonpharmacologic interventions Attentional control: 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 Cold and heat therapy: Advise applying cold (cryotherapy) for reducing pain, edema, inflammation, and muscle spasm. B Advise applying heat for relieving pain and increasing blood flow and elasticity of connective tissues. B Acupressure: offer acupressure (applying pressure to specific relaxation points) for reducing pain and anxiety during ambulance transport after minor trauma. A https://web.pathway.md/diseases/recDXw6lDrVx6e4eb 3/5 6/23/23, 2:02 AM Acute pain Pathway 4. Therapeutic procedures Transcutaneous electrical nerve stimulation: recognize that transcutaneous electrical nerve stimulation has demonstrated evidence from postoperative settings that it can significantly reduce analgesic requirements. A 5. Specific circumstances Patients with fractures: recognize that:. Show 7 more 6. Patient education General counseling: 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 7. Follow-up and surveillance Monitoring of analgesia: 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 References 1. Sa d Hachimi-Idrissi, Viliam Dobias, Wolf E Hautz et al. Approaching acute pain in emergency settings; European Society for Emergency Medicine EUSEM guidelines-part 2 management and recommendations. Intern Emerg Med. 2020 Oct;15 7 1141 1155. Open 2. Sa d Hachimi-Idrissi, Frank Coffey, Wolf E Hautz et al. Approaching acute pain in emergency settings: European Society for Emergency Medicine EUSEM guidelines-part 1 assessment. Intern Emerg Med. 2020 Oct;15 7 1125 1139. Open 3. Deborah Dowell, Kathleen R Ragan, Christopher M Jones et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain United States, 2022. MMWR Recomm Rep. 2022 Nov 4;71 3 1 95. Open 4. Department of Defense/Veterans Affairs. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE USE OF OPIOIDS IN THE MANAGEMENT OF CHRONIC PAIN. VA/DoD. 2022 May. Open 5. Schwenk ES, Viscusi ER, Buvanendran A et al. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018 Jul;43 5 456 466. Open https://web.pathway.md/diseases/recDXw6lDrVx6e4eb 4/5 6/23/23, 2:02 AM Acute pain Pathway 6. Kathleen S Romanowski, Joshua Carson, Kate Pape et al. American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps. J Burn Care Res. 2020 Nov 30;41 6 1129 1151. Open 7. Mohamed Habib Grissa, Houda Baccouche, Hamdi Boubaker et al. Acupuncture vs intravenous morphine in the management of acute pain in the ED. Am J Emerg Med. 2016 Nov;34 11 2112 2116. Open 8. S I Merkel, T Voepel-Lewis, J R Shayevitz et al. The FLACC a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. May-Jun 1997;23 3 293 7. Open 9. Shobha Malviya, Terri Voepel-Lewis, Constance Burke et al. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. 2006 Mar;16 3 258 65. Open https://web.pathway.md/diseases/recDXw6lDrVx6e4eb 5/5