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acute pain

Etiology: 1) surgery 2) trauma a) fractures b) burns or cuts 3) dental work 4) labor & delivery, childbirth Pathology: - serves as a warning of disease or a threat to the body Clinical manifestations: - acute pain begins suddenly & is usually sharp in quality - may be mild & last just a moment - may be severe & last for weeks or months - in most cases, acute pain does not last longer than 6 months - acute pain disappears when the underlying cause of pain has been treated or has healed Complications: - unrelieved acute pain, may lead to chronic pain. Management: 1) use of pain ladder recommended - restrict opiates to severe pain or pain unresponsive to other measures [10] 2) acetaminophen - acetaminophen noninferior to diclofenac alone or to diclofenac plus acetaminophen in reducing acute minor musculoskeletal pain [9] - acetaminophen better than NSAID or NSAID-acetaminophen combination in reducing acute traumatic extremity pain [11[ 3) NSAIDs 4) combination of NSAIDs & opiates more effective than either alone [2] 5) ibuprofen & opioids similarly effective for short-term relief of acute extremity pain when combined with acetaminophen [8] 6) use short-acting opiates for acute pain - avoid use of short-acting opiates for > 3 days for acute nontraumatic pain unrelated to surgery [6] - avoid long-acting opiates including transdermal fentanyl [10] 7) parenteral opiates a) standard dose of morphine (0.1 mg/kg IV) 1] inadequate to treat severe pain in Emergency department [1] 2] adverse effects of opiate administration rare [1] b) avoid meperidine c) hydromorphone 2 mg IV may work better for adults [3] 8) subdissociative-dose IV ketamine (0.3 mg/kg) [4] - intranasal or nebulized ketamine may be an option for treatment of acute pain in elderly [13] 9) acupuncture may reduce pain in the emergency department more effectively (92% vs 78%), faster (16 vs 28 minutes) & more safely than morphine (minor adverse effects 3% vs 57%)* [7] 10) avoid coadministration of opioids with other CNS depressants 11) when switching opioids, lower the dose of the new opioid by at least 25-50% of the calculated equianalgesic dose to account for inter-patient variability in response to opioids [10] 12) at hospital discharge, inquire about existing opioids at home [10] 13) also see pain * commentator not enthused about effectiveness of acupuncture, but noted that in midst of an opioid epidemic, we should be open to alternatives [7]

Specific

periumbilical pain

General

pain [odyn-]

References

  1. Bijur PE et al Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients Ann Emerg Med 2005; 46:362 PMID: 16187470
  2. Ong CK et al Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: A qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010 Apr; 110:1170. PMID: 20142348
  3. Chang AK et al. Randomized clinical trial of efficacy and safety of a single 2-mg intravenous dose of hydromorphone versus usual care in the management of acute pain. Acad Emerg Med 2013 Feb; 20:185 PMID: 23406078
  4. Motov S et al. Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: A randomized controlled trial. Ann Emerg Med 2015 Mar 26 PMID: 25817884
  5. WebMD: pain management guide http://www.webmd.com/pain-management/guide/pain-basics
  6. Centers for Disease Control and Prevention (CDC) Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain. Federal Register. Dec 14, 2015 https://www.federalregister.gov/articles/2015/12/14/2015-31375/proposed-2016-guideline-for-prescribing-opioids-for-chronic-pain - Draft CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-0002
  7. Pallin DJ Acupuncture vs. Morphine for Emergency Department Patients with Pain. Physician's First Watch, Aug 2, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Grissa MH et al. Acupuncture vs intravenous morphine in the management of acute pain in the ED. Am J Emerg Med 2016 Jul 20; PMID: 27475042
  8. Chang AK, Bijur PE, Esses D et al Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department. A Randomized Clinical Trial. JAMA. 2017;318(17):1661-1667 PMID: 29114833 https://jamanetwork.com/journals/jama/article-abstract/2661581 - Kyriacou DN Opioid vs Nonopioid Acute Pain Management in the Emergency Department. JAMA. 2017;318(17):1655-1656 PMID: 29114813 https://jamanetwork.com/journals/jama/article-abstract/2661559
  9. Ridderikhof ML, Lirk P, Goddijn H et al. Acetaminophen or nonsteroidal anti-inflammatory drugs in acute musculoskeletal trauma: A multicenter, double-blind, randomized, clinical trial. Ann Emerg Med 2017 Oct 13 PMID: 29033294 http://www.annemergmed.com/article/S0196-0644(17)31506-8/fulltext
  10. Herzig SJ, Mosher HJ, Calcaterra SL et al Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine. J. Hosp. Med. 2018 April;13(4):263-271 PMID: 29624189 https://www.journalofhospitalmedicine.com/jhospmed/article/161927/hospital-medicine/improving-safety-opioid-use-acute-noncancer-pain - Herzig SJ, Calcaterra SL, Mosher HJ Safe Opioid Prescribing for Acute Noncancer Pain in Hospitalized Adults: A Systematic Review of Existing Guidelines. J Hosp Med. 2018 Apr;13(4):256-262. PMID: 29624188
  11. Msolli MA, Sekma A, Toumia M et al. Acetaminophen, nonsteroidal anti-inflammatory drugs, or combination of both analgesics in acute posttrauma pain: A randomized controlled trial. Acad Emerg Med 2020 Nov 3 PMID: 33145862 https://onlinelibrary.wiley.com/doi/10.1111/acem.14169
  12. Guidelines on the assessment and management of acute pain Institute for Clinical Systems Improvement (ICSI) http://www.icsi.org/knowledge/browse_bydate.asp?catID=29
  13. Almodibeg B, Forget P Challenges of acute pain management in older patients. Age Ageing. 2024 Apr 1;53(4):afae061. PMID: 38557666 https://academic.oup.com/ageing/article/53/4/afae061/7638303