Clinical Practice Guidelines on Emergency Pharmacologic Acute Pain Management (EUSEM, 2020)

European Society for Emergency Medicine

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 17, 2020

In March 2020, the European Society for Emergency Medicine (EUSEM) released clinical practice guidelines on acute pain management in emergency settings, including, as detailed below, with regard to pharmacologic therapies.[1]

Mild to severe pain in the emergency department (ED) and in prehospital settings is subject to management with a wide range of analgesic agents.

Appropriate management of acute pain can usually be achieved with nitrous oxide, an agent with a long history of analgesic use and characterized by a very rapid onset and offset of effect. Moreover, nitrous oxide does not mask injury, and no significant adverse events (AEs) have been observed in association with self-administration by patients.

Frequently used in cases of mild to moderate acute pain, paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are good options for managing mild to moderate pain in the emergency setting. However, an association exists between systemically administered NSAIDs and a number of serious AEs. Moreover, healthcare providers should avoid giving NSAIDs to elderly patients or individuals with renal issues. Additionally, gastrointestinal bleeding and uncontrolled hypertension are contraindications for NSAID use.

Characterized by minimal anti-inflammatory effects, the analgesic dipyrone (metamizole) has been found to be effective in renal colic and acute pancreatitis. However, the drug, which is associated with life-threatening agranulocytosis, has been banned in some countries, while others have restricted its use.

An analgesic mainstay for moderate to severe pain in the prehospital and ED settings, opioids can be administered via a considerable range of routes. Associated with AEs that include nausea and respiratory depression, they should be employed in accordance with institution protocols and monitoring procedures.

Administered at low doses, ketamine is an effective analgesic that can be opioid sparing. Patients can benefit from intranasal employment of the agent when intravenous (IV) access proves difficult, with the efficacy of intranasal ketamine being comparable to that of intranasal fentanyl in children.

A well-tolerated agent that offers rapid, effective analgesia, methoxyflurane can be administered quickly, providing a bridge to other analgesics. For example, using the handheld inhaler, patients can easily self-administer methoxyflurane while IV access for other drugs is being established.

With proven analgesic efficacy in the ED, nerve blocks are characterized by a low risk of AEs and can be opioid sparing. However, administration requires complex and invasive procedures.

Evidence supporting the analgesic usefulness of lidocaine in the ED is currently limited.

For more information, please go to Pain Assessment.

For more Clinical Practice Guidelines, please go to Guidelines.

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