There are a number of situations where the ideal ED analgesic management approach is complex or somewhat controversial. Acute abdominal pain and migraine are two such situations.
ABDOMINAL PAIN Unfortunately, withholding of analgesics in the setting of abdominal pain remains widespread practice that is not evidence based. 18 Early administration of intravenous opiate has been shown to be a safe19 and effective analgesic in patients with acute abdominal pain in the ED and does not have adverse effects on the accuracy of the evaluation,20 the diagnosis, and management.18 Some studies have shown that narcotic administration not only does not mask the diagnosis but actually enhances diagnostic accuracy.21
MIGRAINE The choice of the best analgesic agent for use in the ED to manage a migraine headache remains broad. There have been reported success rates as high as 95 percent for the phenothiazines, chlorpromazine (Thorazine) and prochlorperazine (Compazine). 22 Both drugs were associated with decreasing pain scores, but the effect of prochlorperazine was greater. Headache recurrence has been reported to be as high as 50 percent with 5-hydroxytryptamine agonist (Sumatriptan) or dihydroergotamine (DHE). Headache rate at 24 h was significantly higher for patients who left the ED with persisting headache compared to those who left with no pain. More aggressive ED treatment may result in higher successful treatment rates but may also be associated with more adverse effects from the therapy. Dopamine antagonist, antiemetics, metoclopramide, phenothiazines, haloperidol, Sumatriptan, DHE, NSAIDs, acetaminophen, codeine, and narcotics have all been studied. 23 The relative benefit of these agents or combinations of therapies remains unclear. Ketorolac, meperidine, and saline each produced significant pain reduction in a recent study.24 Opioid use has lost favor due to poor performance in clinical trials as well as the potential to be associated with drug-seeking behavior. 25
Management of pain related to other conditions is discussed in their respective chapters and is outlined in T.§ble.,..3.2-7.
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