Initial ED Pain Management Options in ED

Acetaminophen and NSAIDs

Medication	Dose
Acetaminophen	500-1000 mg PO
	1000 mg IV over 15 minutes
	650 mg PR
Ibuprofen	400-600 mg PO
Naproxen	250-500 mg PO
Ketorolac	10 mg PO or 10-15 mg IV
Indomethacin	25-50 mg PO

Non-Opioids

Medication	Dose
Lidocaine 1%	Local/regional anesthetic Max: 4 mg/kg; 7 mg/kg with epinephrine
	Intra-articular 5-20 mL
Lidocaine 2%	Local/regional anesthetic Max: 4 mg/kg; 7 mg/kg with epinephrine
Lidoderm 5% p	Apply on skin
Bupivacaine 0.25-0.5%	Local/regional anesthetic Max dose: 2.5 mg/kg; 3 mg/kg with epinephrine
Triamcinolone	Intra-articular 2.5-40 mg
Gabapentin	100-300 mg PO
Pregabalin	25 mg PO
Ketamine Subdissociative dose	0.3 mg/kg IV in 100 mL NS over 10 min
	Continuous infusion: 0.15 mg/kg/hr IV (100 mg in 100 mL NS)
	1 mg/kg IN (no more than 1 mL per nostril)

Opioids

Medication	Dose
Oxycodone (5 mg tablet)	1-2 tabs PO
Hydrocodone (5 mg tablet)	1-2 tabs PO
Oxycodone/acetaminophen (5/325 mg tablet)	1-2 tabs PO
Hydrocodone/acetaminophen (5/325 mg tablet)	1-2 tabs PO
Hydrocodone/ibuprofen (2.5/200 mg tablet)	1-2 tabs PO
Morphine IR (15 mg tablet)	1-2 tabs PO
Hydromorphone	Weight-based: 0.015 mg/kg IV titrate Q 15 min
	Fixed dose: 1 mg IV titrate Q 10-15 min
	2-4 mg IM
	2-4 mg PO
Morphine	Weight-based: 0.1 mg/kg IV titrate Q 20 min
	Fixed dose: 5 mg IV titrate Q 10-15 min
	Fixed dose infusion: 10 mg IV in 100 mL NS over 10 min titrate Q 20-30 min
	10-20 mg nebulized with 3 mL NS
Fentanyl	Weight-based: 1-1.5 mcg/kg IV in 100 mL NS over 5-10 min
	Fixed dose: 50-100 mcg IV in 100 mL NS over 10 min
	1-2 mcg/kg IN (no more than 1 mL per nostril)
	2-4 mcg/kg nebulized
Naloxone	(for opioid-induced pruritus) 0.25-0.5 mcg/kg/hr IV (2 mg naloxone in 100 mL NS)

Pain Syndromes

Abdominal Pain (non-traumatic)

Medication	Dose
Ketorolac	10-15 mg IV
Rescue Opioids	Morphine or Fentanyl IV

Abdominal Pain (traumatic)

Medication	Dose
Opioids	Morphine or Fentanyl IV
Acetaminophen	1 g IV over 15 min (adjunct to opioids)

Back Pain (acute)

Medication	Dose
NSAID	Ibuprofen or naproxen
Methocarbamol	1500 mg PO
Diazepam	5 mg PO

Back Pain (chronic)

Medication	Dose
Gabapentin	100-300 mg PO
Pregabalin	25 mg PO
Lidoderm 5% Patch	No more than 4 patches in 24 hr

Dental Pain

Medication	Dose
NSAID	Ibuprofen or naproxen
Dental Blocks	5 mL of Lidocaine (1-2%) or 2 mL of Bupivacaine (0.25-0.5%)

Headache

Oral

Medication	Dose
NSAID	Ibuprofen or naproxen
Butalbital/ acetaminophen/caffeine (50/325/40 mg)	1-2 tabs PO
Metoclopramide	10 mg PO

Parenteral (in preferred order)

Medication	Dose
Metoclopramide	10 mg IV (Slow drip over 10-15 min)
Diphenhydramine	25-50 mg IV
Prochlorperazine	10 mg IV
Chlorpromazine	0.1 mg/kg IV
Sumatriptan	6 mg SQ, repeat with 12 mg SQ (after 1 h)
Dihydroergotamine	0.25 mg IV, repeat with 1 mg (after 1 h)
Valproate	300-1000 mg IV (over 30 min)
Magnesium	2 gm IV (30-60 min)
Droperidol	1-2.5 mg IV 2.5-8 mg IM
Haloperidol	2.5-5 mg IV

Regional Nerve Blocks

Medication	Dose
Paracervical block	5 mL of Lidocaine (1-2%) or 2-3 mL of Bupivacaine (0.25-0.5%)
Occipital nerve block	5 mL of Lidocaine (1-2%) or 2-3 mL of Bupivacaine (0.25-0.5%)

Musculoskeletal Pain (non-traumatic)

Medication	Dose
NSAID	Ibuprofen, naproxen, or indomethacin
Local/Regional Blocks	Lidocaine or bupivacaine ± epinephrine
Neuropathic Pain	Gabapentin 100 mg PO Pregabalin 25 mg PO
NSAID	Ibuprofen, naproxen, or indomethacin
Lidoderm 5% patch	Apply on skin

Renal Colic

Medication	Dose
Ketorolac	10-15 mg IV
Rescue Opioids	Morphine or Fentanyl IV

Sickle Cell Pain Crisis

Intravenous (IV)

Medication	Dose
Opioids	Morphine, fentanyl, or hydromorphone
Ketorolac	10-15 mg IV

Subcutaneous (SQ)

Medication	Dose
Morphine	0.1 mg/kg or 5 mg SQ fixed dose with titration Q 10-15 min
Hydromorphone	1-1.5 mg SQ with titration Q 15 min

Intranasal (IN) / Nebulized

Medication	Dose
Fentanyl	1-2 mcg/kg IN titrate Q 5-10 min
Fentanyl	2-4 mcg/kg nebulized single dose

Intramuscular (IM) route is DISCOURAGED!

Trauma & Burns

Medication	Dose
Local/Regional Blocks	Lidocaine or bupivacaine ± epinephrine
Opioids	Morphine or Fentanyl
Ketorolac	10-15 mg IV
Acetaminophen	1 g IV over 15 min (adjunct to opioids/NSAIDS/ketamine)
Ketamine Subdissociative dose	0.3 mg/kg IV in 100 mL NS over 10 min Continuous infusion: 0.15 mg/kg/hr IV (100 mg in 100 mL NS) Intrnasal 1 mg/kg (no more than 1 mL per nostril)

Opiate-Tolerant Patient or Refractory/Intractable Pain

Consider subdissociative dosing of ketamine.

References

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