PV Card: Initial Pain Medication Options in the Emergency Department

The emergency department (ED) manages acute pain on a daily basis, ranging from non-traumatic back pain to traumatic fractures. Some providers jump immediately to opioids without considering other non-opioid alternatives or start at incorrect doses. In the age of the opioid epidemic (ALiEM-Annals of EM journal club; bookclub discussing Dreamland) and medication errors, choosing the initial right agent(s) and dose(s) are important. Dr. Nick Koch and Dr. Sergey Motov (@PainFreeED) from Maimonides Medical Center present a thoughtful, evidence-based PV reference card on selecting and dosing initial pain medications for ED patients. Also congratulations to Dr. Motov and his team for their recent 2015 Annals of EM publication¹ on subdissociative dose ketamine for analgesia.

PV Card: Initial Pain Medication Options

References

1. Motov S, Rockoff B, Cohen V, et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015;66(3):222-229.e1. [PubMed]
2. Bartfield J, Flint R, McErlean M, Broderick J. Nebulized fentanyl for relief of abdominal pain. Acad Emerg Med. 2003;10(3):215-218. [PubMed]
3. Borland M, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007;49(3):335-340. [PubMed]
4. Galinski M, Dolveck F, Combes X, et al. Management of severe acute pain in emergency settings: ketamine reduces morphine consumption. Am J Emerg Med. 2007;25(4):385-390. [PubMed]
5. Friedman B, Esses D, Solorzano C, et al. A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine. Ann Emerg Med. 2008;52(4):399-406. [PubMed]
6. Lvovschi V, Aubrun F, Bonnet P, et al. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med. 2008;26(6):676-682. [PubMed]
7. Chang A, Bijur P, Campbell C, Murphy M, Gallagher E. Safety and efficacy of rapid titration using 1mg doses of intravenous hydromorphone in emergency department patients with acute severe pain: the “1+1” protocol. Ann Emerg Med. 2009;54(2):221-225. [PubMed]
8. Kostic M, Gutierrez F, Rieg T, Moore T, Gendron R. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med. 2010;56(1):1-6. [PubMed]
9. Patanwala A, Keim S, Erstad B. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother. 2010;44(11):1800-1809. [PubMed]
10. Leong L, Kelly A. Are butyrophenones effective for the treatment of primary headache in the emergency department? CJEM. 2011;13(2):96-104. [PubMed]
11. Andolfatto G, Willman E, Joo D, et al. Intranasal ketamine for analgesia in the emergency department: a prospective observational series. Acad Emerg Med. 2013;20(10):1050-1054. [PubMed]
12. Yeaman F, Meek R, Egerton-Warburton D, Rosengarten P, Graudins A. Sub-dissociative-dose intranasal ketamine for moderate to severe pain in adult emergency department patients. Emerg Med Australas. 2014;26(3):237-242. [PubMed]
13. Beaudoin F, Lin C, Guan W, Merchant R. Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial. Acad Emerg Med. 2014;21(11):1193-1202. [PubMed]
14. Miller J, Schauer S, Ganem V, Bebarta V. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial. Am J Emerg Med. 2015;33(3):402-408. [PubMed]

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