Acute Traumatic - Pain Management CME - Trauma CME - Emergency Department

Acute Traumatic Pain Management in the Emergency Department - Pain Management CME - Trauma CME

About This Resource

Choosing the optimal traumatic pain management strategy has never been more important, and the options have never been so diverse. This Special Report updates you on the latest in analgesia in the emergency department, including these questions:

•  What is the current evidence on nonpharmacologic techniques for pain management?
•  Besides opioids, what is new in systemic analgesia? NSAIDs, APAP, ketamine, alpha-2 agonists, and butyrophenones are reviewed.
•  Regional and local anesthesia can avoid the risks of systemic analgesia or procedural sedation, but what are the best agents and additives to use?
•  What are the easiest and most effective nerve blocks to use for the hands, face, chest, shoulder, and hip?
•  Pain management through nursing protocols and patient-controlled analgesia are showing promising results – is your ED using them?
•  What is new in ED management of chronic pain, and what can be done about drug-seeking behavior?

Product Details

Publication Date: December 1, 2017

CME Expiration Date: December 1, 2020

CME: This enduring material includes 4.5 AMA PRA Category 1 CreditsTM Included as part of the 4 credits, this CME activity is eligible for 4.5 Pain Management CME credits and 4.5 Trauma CME credits.


Christopher R. Tainter, MD, RDMS
Associate Clinical Professor, Department of Anesthesiology, Division of Critical Care, Department of Emergency Medicine, University of California San Diego, San Diego, CA
Peer Reviewers
Ashika Jain, MD, RDMS
Department of Emergency Medicine and Trauma Critical Care, Kings County Hospital Center, Brooklyn, NY
Monica K. Wattana, MD
Fellow, Emergency Oncology/Pain Management, The University of Texas MD Anderson Cancer Center, Houston, TX

Course Director

Andy Jagoda, MD, FACEP
Professor and Chair Emeritus, Department of Emergency Medicine; Director, Center for Emergency Medicine Education and Research, Icahn School of Medicine at Mount Sinai, New York, NY

Table of Contents

  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Pathophysiology
  6. Prehospital Care
  7. Emergency Department Evaluation
  8. Diagnostic Studies
  9. Treatment
    1. Nonpharmacologic Pain Management
    2. Systemic Analgesia
      1. Agents for Systemic Analgesia
        • Opioid Analgesics
        • Nonopioid Analgesics
        • Dissociatives
        • Alpha-2 Agonists
        • Butyrophenones
      2. Route of Administration for Systemic Analgesia
      3. Frequency of Dosing for Systemic Analgesia
    3. Regional Anesthesia
      1. Agents for Regional Anesthesia
      2. Additives for Regional Anesthesia
    4. Topical Anesthesia/Analgesia
      1. Local Infiltration
        • Hematoma Block
      2. Intravenous Regional Anesthesia (Bier Block) (Video)
      3. Regional Nerve Blocks
        • Digital Block (Video)
        • Upper Extremity Nerve Block (Video)
        • Femoral Nerve Block (Video)
        • Intercostal Nerve Block (Video)
        • Interscalene Brachial Plexus Block (Video)
        • Dental Anesthesia (Video)
  10. Special Circumstances
    1. The Unconscious or Critically Ill Patient
    2. Traumatic Abdominal Pain
    3. Pediatric Patients
    4. Geriatric Patients
    5. Drug-Seeking Behavior
    6. Patients With Chronic Pain
  11. Disposition
  12. Summary
  13. Time- and Cost-Effective Strategies
  14. Case Conclusions
  15. Risk Management Pitfalls for Pain Management in the Emergency Department
  16. Clinical Pathway for Management of Pain in the Emergency Department
  17. Tables and Figures
    1. Table 1. Selected Opioid Analgesic Agents
    2. Table 2. Nonopioid Analgesic Agents and NSAIDs
    3. Table 3. Analgesic Routes of Administration
    4. Table 4. Selected Topical and Local Anesthetic Agents
    5. Table 5. Nerves and Anatomical Areas Amenable to Regional Nerve Blocks
    6. Figure 1. Pathophysiology of Pain
    7. Figure 2. Hematoma Block
    8. Figure 3. Intravenous Regional Anesthesia (Bier Block)
    9. Figure 4. Digital Blocks
    10. Figure 5. Femoral Nerve Block
    11. Figure 6. Interscalene Brachial Plexus Block
    12. Figure 7. Apical Periosteal Block
    13. Figure 8. Inferior Alveolar Nerve Block
  18. Videos
  19. References



Painful traumatic injuries account for a large portion of emergency department visits. Injuries may occur through various mechanisms, and many patient and provider factors affect the success of treatment. Not all injuries or patients should be treated in exactly the same fashion, and an understanding of these factors is important to providing optimal care. Regional anesthetic techniques and nonpharmacologic means can help minimize the use of systemic agents that may have unwanted side effects. Diagnostic evaluation should not detract from symptomatic treatment. This evidence-based review summarizes the pathophysiology, historical factors, diagnostic strategies, and demographics that influence the experience of pain and provides recommendations for a variety of treatment options.


Case Presentations

A 65-year-old man with a history of COPD on home oxygen presents to your busy ED with an injury to his right hand from a fall. He states that he was walking across his living room and tripped over the oxygen tubing. As he tried to catch himself on a nearby table, he felt a painful “pop” in his hand. He denies any other injuries or pain, did not hit his head, and had no loss of consciousness or vertigo. In addition to his COPD, he has a history of coronary artery disease, hypertension, and smoking. His vital signs include a normal pulse rate and normal blood pressure. He is breathing rate is 20 breaths/minute, and his oxygen saturation is 93% on 2 liters of oxygen by nasal cannula (which he uses at home). He has scattered expiratory wheezing, but he appears to be in no distress. You notice an obvious rotational deformity with localized swelling of his right hand. The remainder of his examination is unremarkable. He is currently experiencing minimal pain at rest, but he is unable to tolerate any movement of his hand. An x-ray shows an angulated fracture of the fifth metacarpal, which will require reduction. His family is concerned about the risks of medication you might consider because of his other medical problems. You are concerned too, since the last thing you want to do is complicate this patient’s care.

As you start to discuss a plan with the patient, a 35-year-old woman who was the restrained driver in a front-impact motor vehicle crash arrives. Her airbag deployed, and there was significant damage to her car. The paramedics report tachycardia to 120 beats/minute; her other vital signs are normal. Your examination reveals a young woman in pain, with a patent airway, equal breath sounds, strong distal pulses, and tenderness to palpation in her abdomen. She has a band-like ecchymosis across her chest wall and abdomen, consistent with placement of a seat belt. She is neurologically intact and is able to report that she did not hit her head or lose consciousness. She has no other tenderness or deformities. After reporting a normal fingerstick glucose and negative pregnancy test, the nurse asks you if you would like to order something for pain; the answer is yes, but you consider the risk of lowering her blood pressure or changing her exam findings, and you wonder what the safest strategy might be.

As you are finishing your evaluation, a 55-year-old woman presents after she slipped in the shower and hit her right chest against the bathtub. She has a history of chronic low back pain managed with methadone, and she tells you, “I have a really high pain tolerance.” She has no complaints of pain anywhere else, and she did not hit her head or lose consciousness. She has no vomiting or neck pain, and her back pain is unchanged from her baseline. She has no weakness, numbness, or paresthesias, and she denies bowel or bladder dysfunction. Her only complaint is pain in her right chest, which is pleuritic and reproducible with palpation. Initial vital signs are normal, and the primary and secondary survey reveal no additional abnormalities. She appears comfortable but asks you if she can have something strong for the pain.



The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”1 Pain is present in more than half of all emergency department (ED) visits.2 It has profound economic consequences, with losses estimated at $600 billion per year in the United States.3 Approximately 34% of ED visits are related to injuries,4 and the majority of these warrant symptomatic management. Therefore, traumatic pain management is an important part of emergency care.

There has been a great deal of research performed on pain, although particular areas (eg, acute headache) have more data than others. Consequently, recommendations and discussions are not evenly distributed. Indeed, pain management is such a broad topic that fellowships and entire careers are devoted to its study. Numerous studies suggest that, in general, ED pain management is inadequate.5-9

There are many factors that influence appropriate pain management. Patient factors (type of injury, age, medical history) as well as resource availability, cost, and provider familiarity with different options create a diverse array of practice patterns. There is no obvious “correct” strategy to any particular situation, and it benefits both the patient and provider for emergency clinicians to be familiar with the underlying mechanism and treatment options for such conditions. This Special Report provides a foundation for the management of acute traumatic pain in the emergency setting. While not intended to be all-inclusive, it will present an evidence-based appraisal of issues related to this topic.


Critical Appraisal of the Literature

As of September 2017, there were over 700,000 articles related to pain indexed in MEDLINE® and over 1600 reviews in the Cochrane Database of Systematic Reviews. While this provides a wealth of information, not all of this literature is relevant to the practice of emergency medicine. A review was performed, building on previous works10,11 and focusing on issues pertinent to traumatic pain management in the ED. Some 800 articles were identified in MEDLINE® with the search terms emergency trauma analgesia. Additional resources were used, including the Web of Science, The National Guideline Clearinghouse (, articles known to the author, and several textbooks.

Many of the seminal investigations guiding the practice of trauma analgesia were performed by anesthesiologists and surgeons prior to the advent of emergency medicine. This does not negate their utility, but, in some cases, this may limit generalizability to the ED setting.


Risk Management Pitfalls for Pain Management in the Emergency Department

3. “The patient felt better with pain medication, so I didn’t pursue further diagnostic testing.”

While analgesia may improve comfort, careful attention must still be paid to historical elements (eg, high-energy motor vehicle collision) or examination findings (eg, abdominal tenderness) that may be concerning for serious pathology. A focused examination after analgesia may reveal whether abnormal findings can be evoked in an otherwise comfortable patient.

7. “The vital signs were normal, so I decided the patient was not in pain.”

Vital sign abnormalities are not a reliable indicator of pain. In addition to medications that may blunt a response (eg, beta-blockers), each patient’s experience and physiologic response may be different, and some patients may experience significant pain without producing abnormal vital signs.

9. “I had to keep giving him pain medication because he wouldn’t calm down.”

Anxiolysis is an important part of pain control and limiting “wind-up” phenomenon. Often, this can be accomplished by nonpharmacologic means (eg, discussing the patient’s concern, covering a wound, distracting a child, or immobilizing a limb).


Tables and Figures

Pain Management - Trauma - CME - Analgesic Routes of Administration




Intravenous Regional Anesthesia (Bier Block)

Digital Block

Upper Extremity Nerve Block

Femoral Nerve Block

Intercostal Nerve Block

Interscalene Brachial Plexus Block

Dental Anesthesia



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, random­ized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the ref­erence, where available. In addition, the most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

  1. Bonica J. Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain. 1979;6(3):247-248. (Consensus statement)
  2. Chang HY, Daubresse M, Kruszewski SP, et al. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med. 2014;32(5):421-431. (Database review)
  3. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):715-724. (Database review)
  4. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010(26):1-31. (National health statistics)
  5. Beecher HK. Pain in men wounded in battle. Ann Surg. 1946;123(1):96-105. (Case series; 215 patients)
  6. Todd KH, Sloan EP, Chen C, et al. Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments. CJEM. 2002;4(4):252-256. (Cross-sectional survey; 525 patients)
  7. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7(6):620-623. (Review; 198 patients)
  8. Dong L, Donaldson A, Metzger R, et al. Analgesic administration in the emergency department for children requiring hospitalization for long-bone fracture. Pediatr Emerg Care. 2012;28(2):109-114. (Retrospective; 773 patients)
  9. Lewis L, Lasater L, Brooks C. Are emergency physicians too stingy with analgesics? South Med J. 1994;87:7-9. (Retrospective; 401 patients)
  10. Thomas S, ed. Emergency Department Analgesia. New York: Cambridge University Press; 2008. (Textbook)
  11. Curtis L, Morrell T. Pain management in the emergency department. Emerg Med Pract. 2006;8(7):1-28. (Review)
  12. Fink WA Jr. The pathophysiology of acute pain. Emerg Med Clin North Am. 2005;23(2):277-284. (Review)
  13. White LJ, Cooper JD, Chambers RM, et al. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care. 2000;4(3):205-208. (Retrospective; 1073 patients)
  14. McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia. Prehosp Emerg Care. 2002;6(4):406-410. (Retrospective; 124 patients)
  15. Vassiliadis J, Hitos K, Hill CT. Factors influencing prehospital and emergency department analgesia administration to patients with femoral neck fractures. Emerg Med (Fremantle). 2002;14(3):261-266. (Retrospective; 176 patients)
  16. Swor R, McEachin CM, Seguin D, et al. Prehospital pain management in children suffering traumatic injury. Prehosp Emerg Care. 2005;9(1):40-43. (Retrospective; 109 patients)
  17. DeVellis P, Thomas SH, Wedel SK, et al. Prehospital fentanyl analgesia in air-transported pediatric trauma patients. Pediatr Emerg Care. 1998;14(5):321-323. (Retrospective; 131 patients)
  18. Kanowitz A, Dunn TM, Kanowitz EM, et al. Safety and effectiveness of fentanyl administration for prehospital pain management. Prehosp Emerg Care. 2006;10(1):1-7. (Retrospective; 2129 patients)
  19. DeVellis P, Thomas SH, Wedel SK. Prehospital and emergency department analgesia for air-transported patients with fractures. Prehosp Emerg Care. 1998;2(4):293-296. (Retrospective; 130 patients)
  20. Thomas SH, Rago O, Harrison T, et al. Fentanyl trauma analgesia use in air medical scene transports. J Emerg Med. 2005;29(2):179-187. (Prospective; 177 patients)
  21. Krauss WC, Shah S, Thomas SH. Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia. J Emerg Med. 2011;40(2):182-187. (Prospective; 1055 patients)
  22. Galinski M, Dolveck F, Borron SW, et al. A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia. Am J Emerg Med. 2005;23(2):114-119. (Randomized, double-blind; 54 patients)
  23. Baskett PJ. Use of Entonox in the ambulance service. Br Med J. 1970;2(5700):41-43. (Retrospective; 66 patients)
  24. Amey BD, Ballinger JA, Harrison EE. Prehospital administration of nitrous oxide for control of pain. Ann Emerg Med. 1981;10(5):247-251. (Prospective; 88 patients)
  25. Johnson JC, Atherton GL. Effectiveness of nitrous oxide in a rural EMS system. J Emerg Med. 1991;9(1-2):45-53. (Retrospective; 200 patients)
  26. Gausche-Hill M, Brown KM, Oliver ZJ, et al. An evidence-based guideline for prehospital analgesia in trauma. Prehosp Emerg Care. 2014;18 Suppl 1:25-34. (Guideline)
  27. Hyland-McGuire P, Guly H. Effects on patient care of introducing prehospital intravenous nalbuphine hydrochloride. J Accid Emerg Med. 1998;15:99-101. (Prospective; 1000 patients)
  28. Houlihan KP, Mitchell RG, Flapan AD, et al. Excessive morphine requirements after pre-hospital nalbuphine analgesia. J Accid Emerg Med. 1999;16(1):29-31. (Case series; 10 patients)
  29. Porter K. Ketamine in prehospital care. Emerg Med J. 2004;21(3):351-354. (Case series; 32 patients)
  30. Jennings PA, Cameron P, Bernard S, et al. Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med. 2012;59(6):497-503. (Prospective randomized controlled; 135 patients)
  31. Schauer SG, Mora AG, Maddry JK, et al. Multicenter, prospective study of prehospital administration of analgesia in the U.S. combat theater of Afghanistan. Prehosp Emerg Care. 2017:1-6. (Prospective, observational; 532 patients)
  32. Barker R, Schiferer A, Gore C, et al. Femoral nerve blockade administered preclinically for pain relief in severe knee trauma is more feasible and effective than intravenous metamizole: a randomized controlled trial. J Trauma. 2008;64(6):1535-1538. (Prospective randomized; 52 patients)
  33. McRae PJ, Bendall JC, Madigan V, et al. Paramedic-performed fascia iliaca compartment block for femoral fractures: a controlled trial. J Emerg Med. 2015;48(5):581-589. (Randomized controlled non-blinded; 24 patients)
  34. Lang T, Hager H, Funovits V, et al. Prehospital analgesia with acupressure at the Baihui and Hegu points in patients with radial fractures: a prospective, randomized, double-blind trial. Am J Emerg Med. 2007;25(8):887-893. (Prospective randomized double-blind placebo-controlled; 32 patients)
  35. Kober A, Scheck T, Greher M, et al. Prehospital analgesia with acupressure in victims of minor trauma: a prospective, randomized, double-blinded trial. Anesth Analg. 2002;95(3):723-727. (Prospective randomized double-blind placebo-controlled; 60 patients)
  36. Pointer JE, Harlan K. Impact of liberalization of protocols for the use of morphine sulfate in an urban emergency medical services system. Prehosp Emerg Care. 2005;9(4):377-381. (Retrospective; 64,340 patients)
  37. Fullerton-Gleason L, Crandall C, Sklar DP. Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication. Prehosp Emerg Care. 2002;6(4):411-416. (Prospective before/after; 963 patients)
  38. Gallagher RM. Physician variability in pain management: are the JCAHO standards enough? Pain Med. 2003;4(1):1-3. (Review)
  39. Joint Commission. Joint Commission on accreditation of healthcare organizations pain standards for 2001. Available at: Accessed December 1, 2017. (Joint Commission standards)
  40. Todd K, Samaroo N, Hoffman J. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269:1537-1539. (Retrospective; 139 patients)
  41. Todd KH, Deaton C, D’Adamo AP, et al. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11-16. (Retrospective; 217 patients)
  42. Haslam L, Dale C, Knechtel L, et al. Pain descriptors for critically ill patients unable to self-report. J Adv Nurs. 2012;68(5):1082-1089. (Retrospective; 679 subjects)
  43. Tousignant-Laflamme Y, Rainville P, Marchand S. Establishing a link between heart rate and pain in healthy subjects: a gender effect. J Pain. 2005;6(6):341-347. (Observational; 39 volunteers)
  44. Thomas SH, Borczuk P, Shackelford J, et al. Patient and physician agreement on abdominal pain severity and need for opioid analgesia. Am J Emerg Med. 1999;17(6):586-590. (Prospective; 30 patients)
  45. Ducharme J, Barber C. A prospective blinded study on emergency pain assessment and therapy. J Emerg Med. 1995;13(4):571-575. (Prospective blinded cohort study; 384 patients)
  46. Tanabe P, Buschmann M. A prospective study of ED pain management practices and the patient’s perspective. J Emerg Nurs. 1999;25(3):171-177. (Prospective; 203 patients)
  47. Vazirani J, Knott JC. Mandatory pain scoring at triage reduces time to analgesia. Ann Emerg Med. 2012;59(2):134-138. (Prospective before/after; 35,628 patients)
  48. Thomas SH, Andruszkiewicz LM. Ongoing visual analog score display improves emergency department pain care. J Emerg Med. 2004;26(4):389-394. (Prospective randomized controlled; 300 patients)
  49. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med. 2001;8(12):1153-1157. (Prospective; 96 patients)
  50. Gallagher EJ, Bijur PE, Latimer C, et al. Reliability and validity of a visual analog scale for acute abdominal pain in the ED. Am J Emerg Med. 2002;20(4):287-290. (Prospective observational; 101 patients)
  51. Todd K, Funk K, Funk J, et al. Clinical significance of reported changes in pain severity. Ann Emerg Med. 1996;4:485-490. (Prospective; 48 patients)
  52. Gallagher E, Libman M, Bijur P. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med. 2001;38:633-638. (Prospective; 96 patients)
  53. Kelly A. Does the clinically significant difference in visual analog scale pain score vary with gender, age, or cause of pain? Acad Emerg Med. 1998;11:1086-1090. (Prospective; 152 patients)
  54. Fosnocht DE, Chapman CR, Swanson ER, et al. Correlation of change in visual analog scale with pain relief in the ED. Am J Emerg Med. 2005;23(1):55-59. (Prospective observational; 1490 patients)
  55. Bird S, Dickson E. Clinically significant changes in pain along the Visual Analog Scale. Ann Emerg Med. 2001;38:639-643. (Prospective; 77 patients)
  56. Silka P, Roth M, Moreno G. Pain scores improve analgesic administration patterns for trauma patients in the emergency department. Acad Emerg Med. 2004;11:264-270. (Prospective observational; 150 patients)
  57. Bijur P, Latimer C, Gallagher E. Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. Acad Emerg Med. 2003;10(4):390-392. (Prospective cohort; 108 patients)
  58. Berthier F, Potel G, Leconte P, et al. Comparative study of methods of measuring acute pain intensity in an ED. Am J Emerg Med. 1998;16(2):132-136. (Comparison; 290 patients)
  59. Kendrick DB, Strout TD. The minimum clinically significant difference in patient-assigned numeric scores for pain. Am J Emerg Med. 2005;23(7):828-832. (Prospective; 354 patients)
  60. Suraseranivongse S, Santawat U, Kraiprasit K, et al. Cross-validation of a composite pain scale for preschool children within 24 hours of surgery. Br J Anaesth. 2001;87(3):400-405. (Cross-validation; 167 pediatric patients)
  61. Merkel S, Voepel-Lewis T, Shayevitz J, et al. The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293-297. (Observational; 89 children)
  62. McGrath PA, Seifert CE, Speechley KN, et al. A new analogue scale for assessing children’s pain: an initial validation study. Pain. 1996;64(3):435-443. (Comparison; 104 patients)
  63. Gélinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain. 2007;23(6):497-505. (Prospective; 55 patients)
  64. Warden V, Hurley A, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc. 2003;4(1)4:9-15. (Prospective; 19 patients)
  65. Paulson-Conger M, Leske J, Maidl C, et al. Comparison of two pain assessment tools in nonverbal critical care patients. Pain Manag Nurs. 2011;12(4):218-224. (Prospective; 100 patients)
  66. Noble VE, Liteplo AS, Nelson BP, et al. The impact of analgesia on the diagnostic accuracy of the sonographic Murphy’s sign. Eur J Emerg Med. 2010;17(2):80-83. (Randomized double-blind placebo-controlled; 30 patients)
  67. Thomas SH, Silen W, Cheema F, et al. Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: a prospective, randomized trial. J Am Coll Surg. 2003;196(1):18-31. (Prospective randomized double-blind placebo-controlled; 74 patients)
  68. Gallagher EJ, Esses D, Lee C, et al. Randomized clinical trial of morphine in acute abdominal pain. Ann Emerg Med. 2006;48:150-160. (Prospective randomized double-blind placebo-controlled; 160 patients)
  69. Lee H, Ernst E. Acupuncture analgesia during surgery: a systematic review. Pain. 2005;114(3):511-517. (Systematic review; 19 randomized controlled trials)
  70. Jan AL, Aldridge ES, Rogers IR, et al. Does acupuncture have a role in providing analgesia in the emergency setting? A systematic review and meta-analysis. Emerg Med Australas. 2017;29(5):490-498. (Systematic review and meta-analysis; 14 trials, 1210 patients)
  71. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011;152(4):755-764. (Review)
  72. Patterson DR, Jensen MP. Hypnosis and clinical pain. Psychol Bull. 2003;129(4):495-521. (Systematic review)
  73. Patterson DR, Jensen MP, Wiechman SA, et al. Virtual reality hypnosis for pain associated with recovery from physical trauma. Int J Clin Exp Hypn. 2010;58(3):288-300. (Randomized controlled study; 21 patients)
  74. Zacny JP, Lichtor JL, Binstock W, et al. Subjective, behavioral and physiological responses to intravenous meperidine in healthy volunteers. Psychopharmacology. (Berl). 1993;111(3):306-314. (Prospective randomized placebo-controlled crossover; 10 volunteers)
  75. Nelson LS. Opioids. In: Hoffman RS, Goldfrank LR, Howland MA, Lewin NA, Flomenbaum NE, eds. Goldfrank’s Toxicologic Emergencies. 9th ed. New York: McGraw-Hill; 2011. (Textbook)
  76. Kurmis AP, Kurmis TP, O’Brien JX, et al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am. 2012;94(9):815-823. (Review)
  77. Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg Br. 2000;82(5):655-658. (Retrospective; 377 patients)
  78. Bhattacharyya T, Levin R, Vrahas MS, et al. Nonsteroidal antiinflammatory drugs and nonunion of humeral shaft fractures. Arthritis Rheum. 2005;53(3):364-367. (Retrospective; 9995 patients)
  79. Hinz B, Cheremina O, Brune K. Acetaminophen (paracetamol) is a selective cyclooxygenase-2 inhibitor in man. FASEB J. 2008;22(2):383-390. (Clinical trial; 5 human volunteers)
  80. McNicol ED, Ferguson MC, Haroutounian S, et al. Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain. Cochrane Database Syst Rev. 2016(5):CD007126. (Cochrane review; 75 studies, 7200 patients)
  81. Craig M, Jeavons R, Probert J, et al. Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. Emerg Med J. 2012;29(1):37-39. (Randomized double-blind; 55 patients)
  82. Jalili M, Mozaffarpour Noori A, Sedaghat M, et al. Efficacy of intravenous paracetamol versus intravenous morphine in acute limb trauma. Trauma Mon. 2016;21(1):e19649. (Randomized double-blinded clinical trial; 60 patients)
  83. McGuinness SK, Wasiak J, Cleland H, et al. A systematic review of ketamine as an analgesic agent in adult burn injuries. Pain Med. 2011;12(10):1551-1558. (Systematic review)
  84. Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med. 2008;26(9):985-1028. (Systematic review)
  85. Bisanzo M, Nichols K, Hammerstedt H, et al. Nurse-administered ketamine sedation in an emergency department in rural Uganda. Ann Emerg Med. 2012;59(4):268-275. (Observational; 191 patients)
  86. Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006;18(1):37-44. (Systematic review)
  87. Albanese J, Arnaud S, Rey M, et al. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology. 1997;87(6):1328-1334. (Prospective; 8 patients)
  88. Schmidt A, Oye I, Akeson J. Racemic, S(+)- and R(-)-ketamine do not increase elevated intracranial pressure. Acta Anaesthesiol Scand. 2008;52(8):1124-1130. (Clinical trial; 9 pigs)
  89. Bar-Joseph G, Guilburd Y, Tamir A, et al. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. J Neurosurg Pediatr. 2009;4(1):40-46. (Prospective controlled; 30 patients)
  90. Roberts DJ, Hall RI, Kramer AH, et al. Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med. 2011;39(12):2743-2751. (Systematic review; 380 patients)
  91. Bourgoin A, Albanese J, Wereszczynski N, et al. Safety of sedation with ketamine in severe head injury patients: comparison with sufentanil. Crit Care Med. 2003;31(3):711-717. (Prospective randomized double-blind; 25 patients)
  92. Bourgoin A, Albanese J, Leone M, et al. Effects of sufentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients. Crit Care Med. 2005;33(5):1109-1113. (Prospective randomized; 30 patients)
  93. Wang X, Ding X, Tong Y, et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth. 2014;28(6):821-827. (Meta-analysis; 198 patients)
  94. Zeiler FA, Teitelbaum J, West M, et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care. 2014;21(1):163-173. (Systematic review)
  95. Gerlach AT, Murphy CV, Dasta JF. An updated focused review of dexmedetomidine in adults. Ann Pharmacother. 2009;43(12):2064-2074. (Systematic review)
  96. Richards JR, Richards IN, Ozery G, et al. Droperidol analgesia for opioid-tolerant patients. J Emerg Med. 2011;41(4):389-396. (Review)
  97. Sharma SK, Davies MW. Patient-controlled analgesia with a mixture of morphine and droperidol. Br J Anaesth. 1993;71(3):435-436. (Prospective randomized; 50 patients)
  98. Lo Y, Chia YY, Liu K, et al. Morphine sparing with droperidol in patient-controlled analgesia. J Clin Anesth. 2005;17(4):271-275. (Randomized double-blind; 179 patients)
  99. Freedman GM, Kreitzer JM, Reuben SS, et al. Improving patient-controlled analgesia: adding droperidol to morphine sulfate to reduce nausea and vomiting and potentiate analgesia. Mt Sinai J Med. 1995;62(3):221-225. (Prospective randomized; 40 patients)
  100. Yamamoto S, Yamaguchi H, Sakaguchi M, et al. Preoperative droperidol improved postoperative pain relief in patients undergoing rotator-cuff repair during general anesthesia using intravenous morphine. J Clin Anesth. 2003;15(7):525-529. (Prospective randomized double-blind; 84 patients)
  101. Kao LW, Kirk MA, Evers SJ, et al. Droperidol, QT prolongation, and sudden death: what is the evidence? Ann Emerg Med. 2003;41(4):546-558. (Systematic review)
  102. Nuttall GA, Eckerman KM, Jacob KA, et al. Does low-dose droperidol administration increase the risk of drug-induced QT prolongation and torsade de pointes in the general surgical population? Anesthesiology. 2007;107(4):531-536. (Retrospective; 4528 patients)
  103. Schwartz NA, Turturro MA, Istvan DJ, et al. Patients’ perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect on analgesia. Acad Emerg Med. 2000;7(8):857-861. (Randomized double-blinded; 64 patients)
  104. Derry S, Wiffen PJ, Kalso EA, et al. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;5:CD008609. (Cochrane review; 206 studies, 30,700 patients)
  105. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology. 2002;97(5):1274-1280. (Prospective observational; 487 anesthesiologists)
  106. Bhoi S, Sinha TP, Rodha M, et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians. J Emerg Trauma Shock. 2012;5(1):28-32. (Prospective; 50 patients)
  107. Dillion DC, Gibbs M. Local and Regional Anesthesia. In: Tintinalli JE KG, Stapczynski JS, ed. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York: McGraw-Hill; 2011. (Textbook)
  108. Noorily AD, Noorily SH, Otto RA. Cocaine, lidocaine, tetracaine: which is best for topical nasal anesthesia? Anesth Analg. 1995;81(4):724-727. (Prospective randomized; 8 volunteers)
  109. Campbell D, Adriani J. Absorption of local anesthetics. J Am Med Assoc. 1958;168(7):873-877. (Pharmacodynamic measurement; canine and human subjects)
  110. Nole R, Munson NM, Fulkerson JP. Bupivacaine and saline effects on articular cartilage. Arthroscopy. 1985;1(2):123-127. (Clinical trial, porcine and canine)
  111. Chu CR, Izzo NJ, Coyle CH, et al. The in vitro effects of bupivacaine on articular chondrocytes. J Bone Joint Surg Br. 2008;90(6):814-820. (In vitro clinical trial, human chondrocytes)
  112. Dragoo JL, Braun HJ, Kim HJ, et al. The in vitro chondrotoxicity of single-dose local anesthetics. Am J Sports Med. 2012;40(4):794-799. (In vitro clinical trial, human chondrocytes)
  113. Järvelä T, Järvelä S. Long-term effect of the use of a pain pump after arthroscopic subacromial decompression. Arthroscopy. 2008;24(12):1402-1406. (Prospective randomized; 50 patients)
  114. Chow MY, Sia AT, Koay CK, et al. Alkalinization of lidocaine does not hasten the onset of axillary brachial plexus block. Anesth Analg. 1998;86(3):566-568. (Randomized controlled double-blind; 37 patients)
  115. Tetzlaff JE, Yoon HJ, Brems J, et al. Alkalinization of mepivacaine improves the quality of motor block associated with interscalene brachial plexus anesthesia for shoulder surgery. Reg Anesth. 1995;20(2):128-132. (Prospective randomized double-blind placebo-controlled; 40 patients)
  116. Hanna MN, Elhassan A, Veloso PM, et al. Efficacy of bicarbonate in decreasing pain on intradermal injection of local anesthetics: a meta-analysis. Reg Anesth Pain Med. 2009;34(2):122-125. (Meta-analysis; 1224 patients)
  117. Cooper DD, Seupaul RA. Does buffered lidocaine decrease the pain of local infiltration? Ann Emerg Med. 2012;59(4):281-282. (Meta-analysis; 1067 patients)
  118. Popping DM, Elia N, Marret E, et al. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology. 2009;111(2):406-415. (Meta-analysis; 1054 patients)
  119. Brummett CM, Williams BA. Additives to local anesthetics for peripheral nerve blockade. Int Anesthesiol Clin. 2011;49(4):104-116. (Review)
  120. Cheng YJ. Lidocaine skin patch (Lidopat(R) 5%) is effective in the treatment of traumatic rib fractures: a prospective double-blinded and vehicle-controlled study. Med Princ Pract. 2016;25(1):36-39. (Randomized double-blinded; 44 patients)
  121. Ingalls NK, Horton ZA, Bettendorf M, et al. Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures. J Am Coll Surg. 2010;210(2):205-209. (Randomized, double-blind, placebo-controlled; 58 patients)
  122. Zink KA, Mayberry JC, Peck EG, et al. Lidocaine patches reduce pain in trauma patients with rib fractures. Am Surg. 2011;77(4):438-442. (Retrospective cohort; 58 patients)
  123. McGee HT, Fraunfelder FW. Toxicities of topical ophthalmic anesthetics. Expert Opin Drug Saf. 2007;6(6):637-640. (Review)
  124. Calder LA, Balasubramanian S, Fergusson D. Topical nonsteroidal anti-inflammatory drugs for corneal abrasions: meta-analysis of randomized trials. Acad Emerg Med. 2005;12(5):467-473. (Meta-analysis; 5 randomized controlled trials, 459 patients)
  125. Myderrizi N, Mema B. The hematoma block an effective alternative for fracture reduction in distal radius fractures. Med Arh. 2011;65(4):239-242. (Prospective randomized double-blind; 96 patients)
  126. Holmes CM. The history and development of intravenous regional anaesthesia. Acta Anaesthesiol Scand Suppl. 1969;36:11-18. (Review)
  127. Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database Syst Rev. 2010;11:11. (Cochrane review; 18 studies, 1200 patients)
  128. Heath ML. Deaths after intravenous regional anaesthesia. Br Med J (Clin Res Ed). 1982;285(6346):913-914. (Case series; 5 patients)
  129. Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. J Am Acad Orthop Surg. 2001;9(5):345-351. (Review)
  130. Candido KD, Pedicini EL, Winnie AP. Intravenous Regional Anesthesia. In: Reichman EF, Simon R, eds. Emergency Medicine Procedures. New York: McGraw-Hill; 2004. (Textbook)
  131. Hadzic A, Vloka J, Hadzic N, et al. Nerve stimulators used for peripheral nerve blocks vary in their electrical characteristics. Anesthesiology. 2003;98(4):969-974. (Observational; 15 nerve stimulators)
  132. Walker KJ, McGrattan K, Aas-Eng K, et al. Ultrasound guidance for peripheral nerve blockade. Cochrane Database Syst Rev. 2009(4):CD006459. (Cochrane review; 18 trials, 1344 patients)
  133. Wilhelmi BJ, Blackwell SJ, Miller JH, et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg. 2001;107(2):393-397. (Prospective randomized double-blind; 60 patients)
  134. Chowdhry S, Seidenstricker L, Cooney DS, et al. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010;126(6):2031-2034. (Retrospective; 1111 patients)
  135. Ilicki J. Safety of epinephrine in digital nerve blocks: a literature review. J Emerg Med. 2015;49(5):799-809. (Review, 39 articles; 2797 patients)
  136. Keramidas EG, Rodopoulou SG, Tsoutsos D, et al. Comparison of transthecal digital block and traditional digital block for anesthesia of the finger. Plast Reconstr Surg. 2004;114(5):1131-1134. (Prospective randomized double-blind; 50 patients)
  137. Hill RG, Jr, Patterson JW, Parker JC, et al. Comparison of transthecal digital block and traditional digital block for anesthesia of the finger. Ann Emerg Med. 1995;25(5):604-607. (Prospective randomized controlled blinded crossover; 31 patients)
  138. Cummings AJ, Tisol WB, Meyer LE. Modified transthecal digital block versus traditional digital block for anesthesia of the finger. J Hand Surg Am. 2004;29(1):44-48. (Prospective randomized double-blind crossover; 25 patients)
  139. Parker MJ, Griffiths R, Appadu B. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database Syst Rev. 2010;4:4. (Systematic review)
  140. Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anesthesia: the “3-in-1 block.” Anesth Analg. 1973;52(6):989-996. (Prospective randomized; 20 patients)
  141. Guay J, Parker MJ, Griffiths R, et al. Peripheral nerve blocks for hip fractures. Cochrane Database Syst Rev. 2017;5:CD001159. (Cochrane review; 31 trials, 1760 patients)
  142. Truitt MS, Murry J, Amos J, et al. Continuous intercostal nerve blockade for rib fractures: ready for primetime? J Trauma. 2011;71(6):1548-1552. (Prospective; 102 patients)
  143. Khalil KG, Boutrous ML, Irani AD, et al. Operative intercostal nerve blocks with long-acting bupivacaine liposome for pain control after thoracotomy. Ann Thorac Surg. 2015;100(6):2013-2018
  144. Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med. 2011;18(9):922-927. (Prospective randomized; 42 patients)
  145. Raeyat Doost E, Heiran MM, Movahedi M, et al. Ultrasound-guided interscalene nerve block vs procedural sedation by propofol and fentanyl for anterior shoulder dislocations. Am J Emerg Med. 2017;35(10):1435-1439. (Randomized controlled trial; 60 patients)
  146. Vreeland DL, Reader A, Beck M, et al. An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve block. J Endod. 1989;15(1):6-12. (Prospective; 30 patients)
  147. Reichman EF, Kern KP. Dental Anesthesia and Analgesia. In: Reichman E, Simon R, eds, ed. Emergency Medicine Procedures. New York: McGraw-Hill; 2004. (Textbook)
  148. Marco CA, Plewa MC, Buderer N, et al. Self-reported pain scores in the emergency department: lack of association with vital signs. Acad Emerg Med. 2006;13:974-979. (Retrospective observational; 1063 patients)
  149. Cope Z. Early Diagnosis of the Acute Abdomen. 1st ed. New York: Oxford University Press; 1921. (Textbook)
  150. LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med. 1997;15(6):775-779. (Prospective randomized placebo-controlled; 48 patients)
  151. Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996;3(12):1086-1092. (Prospective double-blind placebo-controlled; 75 patients)
  152. Zoltie N, Cust MP. Analgesia in the acute abdomen. Ann R Coll Surg Engl. 1986;68(4):209-210. (Prospective double-blind placebo-controlled; 288 patients)
  153. Attard AR, Corlett MJ, Kidner NJ, et al. Safety of early pain relief for acute abdominal pain. BMJ. 1992;305(6853):554-556. (Prospective randomized placebo-controlled; 100 patients)
  154. Manterola C, Vial M, Moraga J, et al. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2011(1):CD005660. (Cochrane review; 8 studies)
  155. Diercks DB, Mehrotra A, Nazarian DJ, et al. Clinical policy: critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med. 2011;57(4):387-404. (Clinical policy)
  156. Brown J, Klein E, Lewis C, et al. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42:197-205. (Retrospective; 2828 patients)
  157. Selbst S, Clark M. Analgesia use in the emergency department. Ann Emerg Med. 1990;19:1010-1013. (Retrospective; 268 patients)
  158. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: patterns of analgesic utilization. Pediatrics. 1997;99(5):711-714. (Retrospective; 80 patients)
  159. Platts-Mills TF, Esserman DA, Brown DL, et al. Older US emergency department patients are less likely to receive pain medication than younger patients: results from a national survey. Ann Emerg Med. 2011. (Retrospective survey; 88,031 ED visits)
  160. Jones J, Johnson K, McNinch M. Age as a risk factor for inadequate emergency department analgesia. Am J Emerg Med. 1996;14:157-160. (Retrospective cohort; 231 patients)
  161. Duggleby W, Lander J. Cognitive status and post-operative pain: older adults. J Pain Symptom Manage. 1994;19:19-27. (Prospective; 60 patients)
  162. Morrison R, Magaziner J, Gilbert M. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol. 2003;58:76-81. (Prospective; 541 patients)
  163. Hohl C, Dankoff J, Colacone A, et al. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med. 2001;38:666-671. (Retrospective; 283 patients)
  164. Beyth R, Shorr R. Medication Use. In: Duthie E, Katz P, eds. Duthie: Practice of Geriatrics. 3rd ed. Philadelphia, PA: WB Saunders; 1998. (Textbook chapter)
  165. Griffin M, Yared A, Ray W. Nonsteroidal anti-inflammatory drugs and acute renal failure in elderly persons. Am J Epidemiol. 2000;151:488-496. (Re