Management of Pain in the Emergency Department

Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research. 1. Introduction “Pain is, with very few, if indeed any exceptions, morally and physically a mighty and unqualified evil. And, surely, any means by which its abolition could possibly be accomplished, with security and safety, deserves to be joyfully and gratefully welcomed by medical science” [1], Sir James Young Simpson, administerer of the first obstetrical anesthesia. Addressing patient’s pain is one of the most important contributions ED providers can make. The frequency with which pain is the impetus for an ED visit, the significance of pain relief to individual patients (and family), and the relative ease with which pain can often be ameliorated render analgesia a prime—and achievable—target for optimization of a patient’s ED care. In considering pain care in the ED, some general principles should be kept in mind; these are reviewed in the initial part of this discussion. The next subject to consider is the question of whether there is need for discussion on pain care in the ED. The case for focus on pain management is bolstered by results of an assessment of the status quo of ED analgesia practices. Rather than simply identifying areas in which ED practitioners are performing suboptimally, the discussion will also include recommendations for overcoming barriers to appropriate pain care. Specific analgesic approaches will be addressed, with attention to various patient populations in which analgesia care is historically poor or controversial. The goal of this review is not to be a comprehensive discussion of all matters related to ED pain assessment and care; the subject is simply too broad (a