Introduction
Emergency pain medications are important for comfort and also become factors dictating the success or failure of treatment in an emergency setting. Pain is acute and sharp, resulting from a wide spectrum of causes that range from trauma and surgery to underlying chronic diseases. Timely and effective pain management is particularly challenging in the ED, where early assessment and intervention can dramatically alter patient outcomes. This paper discusses some of the drugs most commonly prescribed in the emergency room for pain control over all parts of the body, their use, action, and considerations.
1. Non-steroidal anti-inflammatory drugs (NSAIDs)
3. Most Common Drugs:
a. Ibuprofen (Advil, Motrin)
b. Ketorolac (Toradol)
c. Naproxen (Aleve)
Indications and Use: NSAIDs are often first-line therapy for mild or moderate pain, particularly in situations where inflammation is a prominent feature, for example, injury sprains or arthritic pain. They can be administered orally, but intravenously (IV) are also used for acute episodes.
Mechanism of Action: NSAIDs inhibit the cyclooxygenase (COX) enzymes, which are very vital in the production of prostaglandins. These are compounds that have a role in inflammation, pain, and fever.
Administration and Dosage:
Ibuprofen: 400-800 mg orally every 6-8 hours as needed, with a daily maximum of 3200 mg.
Ketorolac: 15-30 mg IV every 6 hours, not to exceed 120 mg in 24 hours, and often used for short periods because of its potency.
Precautions: NSAIDs should be used cautiously in patients with kidney disease, gastrointestinal problems such as ulcers, or cardiovascular conditions. The drugs are contraindicated in patients with active bleeding or known allergies to NSAIDs.
2. Acetaminophen (Tylenol)
Indications and Use: Acetaminophen is administered for mild to moderate pain and fever. Often used as an adjunct with other analgesics for added benefit in pain control without appreciable increase in side effects. It is effective for use with headaches, dental pain, and mild musculoskeletal aches.
It is reported to act centrally in the central nervous system, with elevation of the pain threshold requiring more painful stimuli to be perceived.
Administration and dosage:
Adults take 500-1000 mg orally every 4-6 hours, to a maximum of 3000 mg per day.
Precautions: Generally, acetaminophen is safe but very toxic to the liver at high doses. Patients with a pre-existing disease in the liver or those who consume alcohol regularly should use it with caution.
3. Opioids
Common Drugs:
a. Morphine
b. Fentanyl
c. Hydromorphone (Deluded)
Indications and Use: Opioids are reserved for severe pain that cannot be controlled by NSAIDs or acetaminophen alone, such as fractures, burns, or major trauma. They offer strong analgesia but should be used with caution due to side effects and potential for addiction.
Mechanism of Action: The opioids exert their action on the opioid receptors located in the central nervous system, which include the brain and spinal cord. Opioids will inhibit the ascending pain signals and provide a reassuring effect. This class of drugs also exerts a sedative effect. Patients with high anxiety associated with pain may be aided by this effect.
Administration and Dosage:
Morphine: 2-10 mg IV every 2-4 hours as needed.
Fentanyl: 25-100 mcg IV, titrate to effect due to rapid onset and potency.
Precautions: Opioids tend to cause respiratory depression, more so in higher doses or combined with other CNS depressants. They are best used under close observation, particularly for patients who have any form of respiratory or renal impairment. In addition, opioids can be habit-forming and abused.
4. Adjuvant Analgesics
These are not analgesics per se but have been found useful for certain kinds of pain, such as neuralgic pain.
Examples:
a. Gabapentin (Neurontin)
b. Pregabalin (Lyrica)
c. Amitriptyline (Elavil)
Indications and Use: Adjuvant analgesics are particularly useful for neuropathic pain, which can be caused by nerve damage, shingles, or other conditions such as fibromyalgia. They are also useful for chronic pain conditions that are insensitive to ordinary painkillers.
Mechanism of Action:
a. Gabapentin and pregabalin inhibit the activity of excitatory neurotransmitters in the brain and spinal cord.
b. Amitriptyline is a tricyclic antidepressant that alters the levels of neurotransmitters that can affect pain perception.
Administration and Dosage:
Gabapentin: Start at 300 mg add and titrate up to affect.
Pregabalin: Start at 75 mg BID. Titrate based on response.
Precaution. They can cause drowsiness and dizziness. Keep a close eye on patients using concomitant CNS depressants.
5. Local Anesthetics
Common Medications:
Lidocaine Bupivacaine
Indications and Use: Local anesthetics function by blocking the transmission of pain from nerves to the brain in one area of the body, providing a localized analgesic effect. Common use includes local procedures, dental pain, or nerve blocks.
Mechanism of Action: Sodium channels on nerve cells are blocked, which prevents pain from going to the brain, allowing for effective pain relief with no systemic effects.
Administration and Dosage:
Lidocaine: Comes in a 1-5% solution for injection, depending on the procedure and area being treated.
Bupivacaine: It is commonly used for more long-acting nerve blocks. Concentration is between 0.25 and 0.5 percent.
Cautions: Local anesthetics must be administered with caution in order to avoid systemic toxicity, which is much more dangerous while injecting drugs into areas that have a rich blood supply. Overdose may sometimes prove fatal with severe side effects such as seizures or heart problems.
Conclusion
Management of acute pain in the emergency setting balances the best relief possible with patient safety. Pain control medication chosen depends on the intensity and cause of the pain, including the background medical history of the patient. All these drugs fall into the categories of NSAIDs, acetaminophen, opioids, adjuvants, or local anesthetics; each has a specific use. Each patient requires assessment and observation of any untoward effect or complication to ensure proper and safe pain relief management.
