Advanced Concepts and Controversies in Emergency Department Pain Management

Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain

STUDY OBJECTIVES

Ketorolac is a commonly used nonopioid parenteral analgesic for treating emergency department (ED) patients with acute pain. Our systematic review aims to summarize the available evidence by comparing the efficacy and safety of differing ketorolac dosing strategies for acute pain relief in the ED.

METHODS

The review was registered on PROSPERO (CRD42022310062). We searched MEDLINE, PubMed, EMBASE, and unpublished sources from inception through December 9, 2022. We included randomized control trials of patients presenting with acute pain to the ED, comparing ketorolac doses less than 30 mg (low dose) to ketorolac doses more than or equal to 30 mg (high dose) for the outcomes of pain scores after treatment need for rescue analgesia, and incidence of adverse events. We excluded patients in non-ED settings, including postoperative settings. We extracted data independently and in duplicate and pooled them using a random-effects model. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool and the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach.

RESULTS

This review included 5 randomized controlled trials (n=627 patients). Low-dose parenteral ketorolac (15 to 20 mg), as compared to high-dose ketorolac (≥30 mg), probably has no effect on pain scores (mean difference 0.05 mm lower on 100 mm visual analog scale, 95% confidence interval [CI] -4.91 mm to +5.01 mm; moderate certainty). Further, low-dose ketorolac at 10 mg may have no effect on pain scores compared to high-dose ketorolac (mean difference 1.58 mm lower on 100 mm visual analog scale, 95% CI -8.86 mm to +5.71 mm; low certainty). Low-dose ketorolac may increase the need for rescue analgesia (risk ratio 1.27, 95% CI 0.86 to 1.87; low certainty) and may have no difference on rates of adverse events (risk ratio 0.84, 95% CI 0.54 to 1.33; low certainty).

CONCLUSION

In adult ED patients with acute pain, parenteral ketorolac given at doses of 10 mg to 20 mg is probably as effective in relieving pain as doses of 30 mg or higher. Low-dose ketorolac may have no effect on adverse events, but these patients may require more rescue analgesia. This evidence is limited by imprecision and is not generalizable to children or those at higher risk of adverse events.

Congruency of nurse-patient pain scoring in the emergency department: a cross-sectional observational study

Aim: To examine the congruency between patient self-reporting and nurse assessment of pain in the emergency department (ED) through the use of the numerical rating scale (NRS) and visual analogue scale (VAS). Materials & methods: Patient self-reporting of pain and nurse assessments were concurrently conducted using the NRS and VAS. Results & conclusion: Self-reported pain assessment was collected from 200 ED patients in parallel with their corresponding nurse-reported pain scores, conducted by 67 ED nurses. Although nurse-patient pain scoring was associated with a high congruency using both NRS and VAS (88.2 and 91.5%, respectively), nurses still underestimated patients' pain intensity using both tools (t = 2.37 and 2.60; p = 0.007 and 0.010 and CI: 0.17-1.1 and 0.06-0.46, respectively). Some nurse-patient characteristics showed relationships with a discrepancy in pain scoring.

Pain management in the emergency department: a clinical review

Pain is one of the most common reasons for patients to visit the emergency department. The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities. This clinical review is set to provide evidence-based answers to these challenging questions.

Expert review and recommendations for the management of acute, chronic, and neuropathic pain in Qatar

BACKGROUND

Pain management is an evolving area of expertise in Qatar. Gaps in knowledge, inadequate training for physicians and nurses, and the absence of policies/guidelines are the main barriers to effective pain management in Qatar. In addition, the use of certain pain medication, especially opioids, is highly regulated, limiting their availability in outpatient pain management. These factors are responsible for the undertreatment of pain in Qatar. This study aimed to standardize evidence-based local recommendations for pharmacological treatment of pain in Qatar.

METHODS

An expert panel of physicians from different disciplines, with experience in diagnosis and treatment of the three pain types (i.e., acute, chronic, and neuropathic), was convened for two face-to-face meetings in Doha, Qatar, on November 29, 2019, and on February 22, 2020, with subsequent virtual meetings. A literature search was performed on Medline and Google Scholar databases from inception till December 2019, and all relevant articles were selected. Based on these articles and repeated feedback from the authors, the final pain treatment protocols were developed.

RESULTS

Recommendations for the treatment of acute pain, based on pain severity, followed three approaches: acetaminophen/paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) for mild pain and moderate pain and referral to a pain specialist for severe pain. Acetaminophen/paracetamol or NSAIDs is recommended for chronic pain, and the use of opioids was strongly discouraged because of its long-term side effects. For neuropathic pain, tricyclic antidepressants or gabapentin or pregabalin or serotonin-norepinephrine reuptake inhibitors were recommended first-line agents. Non-responders must be referred to neurologists or a pain specialist.

CONCLUSION

The expert panel provides recommendations for the management of acute, chronic, and neuropathic pain based on international guidelines adapted to local practice and treatment availability in Qatar. More importantly, the panel has recommended taking extreme caution in the use of opioids for long-term management of chronic pain and to refer the patient to a pain specialist clinician as required.

Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis

OBJECTIVE

Musculoskeletal pain control is essential in the management of trauma patients in the emergency department (ED). Here, we performed a network meta-analysis of the use of analgesics to manage traumatic musculoskeletal pain.

METHOD

This network meta-analysis (NMA) protocol was registered in PROSPERO (CRD42020150145). Electronic databases were searched for randomized controlled trials comparing systemic pharmaceutical interventions for treating traumatic musculoskeletal pain in the ED setting. The outcomes were global efficacy and changes in pain intensity.

RESULTS

Eighteen studies (2656 patients, four medication classes) met the inclusion criteria. The top-ranking medication class for global efficacy was nonsteroidal anti-inflammatory drugs (NSAIDs; network odds ratio: 0.52, 95% credible interval: 0.34-0.81, surface under the cumulative ranking curve score: 86). No interventions were more effective at decreasing pain intensity than opioids at 60 min.

CONCLUSION

NSAIDs were the most effective medications for treating traumatic musculoskeletal pain, and combination therapies may not have advantages in the ED setting.

Emergence From the COVID-19 Pandemic and the Care of Chronic Pain: Guidance for the Interventionalist

BACKGROUND:

The current Coronavirus Disease (COVID-19) pandemic led to a significant disruption in the care of pain from chronic and subacute conditions. The impact of this cessation of pain treatment may have unintended consequences of increased pain, reduced function, increased reliance on opioid medications, and potential increased morbidity, due to the systemic impact of untreated disease burden. This may include decreased mobility, reduction in overall health status, and increase of opioid use with the associated risks.

METHODS:

The article is the study of the American Society of Pain and Neuroscience (ASPN) COVID-19 task force to evaluate the policies set forth by federal, state, and local agencies to reduce or eliminate elective procedures for those patients with pain from spine, nerve, and joint disease. The impact of these decisions, which were needed to reduce the spread of the pandemic, led to a delay in care for many patients. We hence review an emergence plan to reinitiate this pain-related care. The goal is to outline a path to work with federal, state, and local authorities to combat the spread of the pandemic and minimize the deleterious impact of pain and suffering on our chronic pain patients.

RESULTS:

The article sets forth a strategy for the interventional pain centers to reemerge from the current pandemic and to set a course for future events.

CONCLUSIONS:

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Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative

OBJECTIVES

Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain.

PATIENTS AND METHODS

A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important.

RESULTS

Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%).

CONCLUSION

These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.

Impact of the World Health Organization Pain Treatment Guidelines and the European Medicines Agency Safety Recommendations on Nonsteroidal Anti-Inflammatory Drug Use in Lithuania: An Observational Study

Background and objective: Irrational use of nonsteroidal anti-inflammatory drugs (NSAIDs) is the main cause of adverse effects-associated hospitalizations among all medication groups leading to extremely increased costs for health care. Pharmacoepidemiological studies can partly reveal such issues and encourage further decisions. Therefore, the aim of our study was to evaluate the utilization of non-opioid analgesics (ATC classification N02B and M01A) in Lithuania, and to compare it with that of other Baltic and Scandinavian countries in terms of compliance to the WHO pain treatment guidelines and the EMA safety recommendations on NSAID use. Materials and methods: The dispensing data were obtained from the sales analysis software provider in the Baltic countries (SoftDent, Ltd., Kaunas, Lithuania); State Medicine Control Agencies of Lithuania, Latvia, and Estonia; Norwegian Prescription Database; Swedish Database for Medicines; and Danish Prescription Database. Data included the utilization of both prescription and over-the-counter drugs. Utilization was expressed in defined daily doses (DDD)/1000 inhabitants/day. Results: During the 11-year period, the utilization of drugs belonging to the N02B and M01A groups increased by 22.8%, from 58.37 in 2005 to 71.68 DDD/1000 inhabitants/day in 2016 in Lithuania. Contrary to the WHO guidelines on pain management, all Baltic countries were more likely to use NSAIDs than other analgesics and antipyretics: in 2015, the drugs of the M01A group were used 6.04, 5.79, and 6.11 times more than those of N02B in Lithuania, Estonia, and Latvia, respectively, whereas the Scandinavian countries preferred the N02B to the M01A group: in Denmark and Sweden, the utilization of other analgesics and antipyretics was 2.33 and 1.24, respectively, times higher than that of NSAIDs. In Norway, the use of both groups was similar. In the Scandinavian countries, paracetamol was the analgesic of first choice, whereas, in Lithuania, it took only the third place. The most popular drug in Lithuania was diclofenac, and its utilization accounted for 30.04% of all non-opioid analgesics in 2016. Although the European Medicines Agency (EMA) restricted the use of certain NSAIDs, i.e., cyclooxygenase-2 (COX-2) inhibitors, nimesulide, and diclofenac, their use consistently increased by 15.91, 2.83, and 1.41 times, respectively, showing incompliance with the international guidelines. Conclusions: Neither the EMA safety policy on NSAID use nor the WHO pain treatment guidelines had a sufficient impact on the rational use of NSAIDs in Lithuania. The use of NSAIDs restricted by the EMA (diclofenac, COX-2 inhibitors, nimesulide, and piroxicam) remains high or even increases, while the utilization of safer alternatives (paracetamol and naproxen) remains relatively low as compared with the Scandinavian countries. Incompliance with international guidelines may result in increased morbidity, mortality and higher costs for health care.

Pain assessment in the Emergency Department. Correlation between pain rated by the patient and by the nurse. An observational study

BACKGROUND AND AIM OF THE STUDY

Pain is always present in the Emergency Department (ED), but is often underestimated. The primary purpose of this study is to analyze the degree to which the intensity of pain is underestimated or overestimated in the perception of the nurse and the patient in the ED. The secondary objective of this research is to study possible factors that lead to these discrepancies in assessment.

METHODS

The observational study was carried out in two Hospitals in Central Italy. The sample population was based on 130 patients and 26 nurses. A questionnaire was given to the patients who provided personal data followed by information regarding their pain, including an assessment of the intensity of pain on a scale from 0 to 10. A similar questionnaire was given to the nurses.

RESULTS

The average score based on the numeric rating scale (NRS) to assess the intensity of pain perceived by the patients is 6.16, while the numerical average estimated by the nurses based on their assessment is 5. Using the t test we found that the average between nurse and patient assessments was very significant. The analysis of the nurses' characteristics and professional experiences, age, years of employment and years of service in the ED are all significant variables affecting the discrepancy between the nurses' and patients' assessments of pain. As previous studies have shown, nurses tend to underestimate the degree of pain. In fact, in only 55.5% of the cases was there a correspondence in the evaluations of the intensity of pain done by nurses and patients, and in no case did the nurses' evaluation exceed that of the patients.

CONCLUSIONS

This study reveals the persistent difficulty in pain management, while attempting contemporaneously to communicate the importance of the assessment, since adequate understanding of pain renders it possible to recognize and treat it.

Perception and Practice Among Emergency Medicine Health Care Providers Regarding Discharging Patients After Opioid Administration

PURPOSE

This study aimed to determine the current attitudes, perceptions, and practices of emergency medicine providers and nurses (RNs) regarding the discharge of adult patients from the emergency department (ED) after administration of opioid analgesics.

METHODS

A cross-sectional survey was administered at 3 hospital sites with a combined annual ED census of >180,000 visits per year. All 59 attending emergency physicians (EPs), 233 RNs, and 23 advanced practice clinicians (APCs) who worked at these sites were eligible to participate.

FINDINGS

Thirty-five EPs (59.3%), 88 RNs (37.8%), and 14 APCs (60.9%) completed the survey for an overall response rate of 51.75%. Most respondents were female (95 [69.9%]). The factor ranked most important to consider when discharging a patient from the ED after administration of opioids was the patient's functional status and vital signs (median, 2.00; interquartile range, 2.00-3.50). More RNs (84 [96.6%]) than EPs (29 [82.9%]) reported that developing an ED policy or guideline for safe discharge after administration of opioids is important to clinical practice (P = 0.02). Only 8 physicians (23.5%) reported that they did not prescribe intramuscular morphine, and 15 (42.9%) reported that they did not prescribe intramuscular hydromorphone. EPs (7 [20.0%]) and RNs (3 [3.4%]) differed in regard to whether they were aware if any patients to whom they administered an opioid had experienced an adverse drug-related event (P = 0.01). Most EPs (24 [68.6%]) and RNs (54 [61.4%]) believed that the decision for patient discharge should be left to both the emergency medicine provider and the RN.

IMPLICATIONS

Most study participants believed that developing a policy or guideline for safe discharge after administration opioids in the ED is important to clinical practice. Only a few physicians reported that they did not prescribe intramuscular hydromorphone or morphine. Most participants believed the discharge decision after administration of opioids in the ED should be primarily determined by both the emergency medicine provider and the RN.

Adjunct Analgesic Use for Acute Pain in the Emergency Department

Purpose: Multimodal analgesia is common practice in the postoperative setting, but the utility of adjunctive analgesia in the emergency department (ED) is less understood. The primary objective of this study was to analyze ED prescriber ordering habits for adjunct nonopioid pain medication for opioid-naïve patients who require intravenous (IV) morphine or hydromorphone for acute pain. Secondary objectives were to assess initial and total opioid consumption in morphine equivalent units (MEU), pain scores, and ED length of stay (LOS) between groups. Methods: A retrospective chart review of adult patients who presented to the ED at a large academic medical center and received IV morphine or hydromorphone for acute pain was conducted. Patients were analyzed according to initial opioid received and presence or absence of adjunct nonopioid analgesics. Results: A total of 102 patient charts were analyzed. Adjunctive nonopioid analgesics were ordered on 38% of patients. Patients who received an adjunct nonopioid analgesic received a smaller mean initial opioid dose than those who did not (4.73 vs 5.48 MEU, p = .08). Initial pain score reduction on the 11-point Numeric Rating Scale (NRS) did not differ between patients who received adjunct analgesics versus those who did not (3 vs 4, p = .75). Patients who received adjunct analgesics were associated with a decreased ED LOS (294 vs 342 minutes, p = .04). Conclusion: A small proportion of patients with acute pain received a nonopioid analgesic in conjunction to IV opioids. Further studies are warranted to assess the impact of adjunct analgesics for patients with acute pain.

The Use of Intravenous Lidocaine for the Management of Acute Pain Secondary to Traumatic Ankle Injury: A Case Report

Sports-related injuries are a frequent cause of visits to the emergency department (ED) across the United States. A majority of these injuries affect the lower extremities with the ankle as the most frequently reported site. Most sports-related injuries are not severe enough to require inpatient hospitalization; however, they often lead to acute distress and pain which require prompt treatment with analgesics. Approximately 22% of patients who presented to the ED required pharmacotherapy for acute pain management. Opioids have been traditionally used for the management of severe acute pain in the ED; however, there are growing concerns for opioid overuse and misuse. As a result, there is growing controversy regarding the appropriate selection of analgesic agents, optimal dosing, and need for outpatient therapy which has contributed to changes in prescribing patterns of opioids in the ED. Lidocaine, a class 1b antiarrhythmic, has been utilized as an analgesic agent. Its use has been documented for the management of intractable chronic pain caused by cancer, stroke, neuropathies, or nephrolithiasis. However, literature describing the use of intravenous lidocaine for the management of acute pain secondary to trauma is limited to a single case series. This case report describes the use of intravenous lidocaine in a 17-year-old male who presented to the ED in acute distress secondary to ankle dislocation and fracture. This report serves to describe additional clinical experience with intravenous lidocaine for the management of acute pain secondary to ankle fracture in the emergency department.

Meperidine (pethidine) versus morphine in acute pain management of opioid-dependent patients

The present study aimed to evaluate the effectiveness of morphine and meperidine (pethidine) as pain relief in opioid-dependent patients with acute pain. A total of 122 opioid-dependent patients with acute pain were included in the study. Their pain severity was assessed, using visual analog scale (VAS) scores ranging from 0 to 10. The patients randomly received intravenous morphine (up to 0.15 mg/kg) or meperidine (up to 1.5 mg/kg) for pain control by patient control analgesia (PCA) pump. The clinical opioid withdrawal scale (COWS) was employed for the assessment of withdrawal symptoms. The pain relief and the emergence of withdrawal symptoms were measured at 15, 30, and 60 minutes after drug administration. The patients who received morphine reported a better pain control compared to those who received meperidine (mean ± standard deviation [SD] VAS scores 4.11±1.90 vs 5.85±2.08 at the end of the study; P<0.001). On the other hand, the patients who received meperidine indicated prominent withdrawal symptoms (mean ± SD COWS scores 4.80±2.18 vs. 1.98±0.82 at the end of the study; P<0.001). Our findings revealed that morphine can be recommended in acute pain management of opioid-dependent patients. In addition, emergency physicians should ask their patients about any drug dependence before selecting the appropriate drug for their acute pain management.