Initial Pain Management Options

Authors: Nick Koch, MD, Sergey Motov, MD
Updated: 10/23/2015

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% patch 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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