Evidence-based guideline for multimodal analgesia, opioid stewardship, ultrasound-guided regional anesthesia, and procedural sedation agents and protocols in the ED.
A comprehensive, evidence-based clinical guideline for acute pain management and procedural sedation in the emergency department. This resource synthesizes recommendations from the major emergency medicine professional societies, anesthesiology organizations, pain medicine societies, and accreditation bodies into a single integrated reference for emergency physicians, advanced practice providers, emergency nurses, and all clinicians who manage acute pain and perform procedural sedation in the ED setting.1 2 3 4 5 6 7 8
Acute pain is the most common presenting complaint in emergency departments, accounting for more than 70% of all ED visits. Despite this, oligoanalgesia — the undertreatment of pain — remains a pervasive and well-documented problem, with studies consistently showing that 40–60% of patients with moderate to severe pain receive inadequate analgesia. The emergency department occupies a unique position in the healthcare system as both the front line for acute pain management and the setting where most procedural sedation occurs outside of operating rooms. The evolution of ED pain management over the past two decades has been marked by two parallel revolutions: the recognition that multimodal, opioid-sparing analgesia produces superior outcomes compared with opioid monotherapy, and the expansion of emergency physician–performed regional anesthesia and procedural sedation as core competencies. This guideline addresses the entire spectrum of ED pain management and procedural sedation — from initial pain assessment through non-opioid first-line therapies, opioid prescribing best practices, ultrasound-guided nerve blocks, topical and local anesthesia, procedural sedation agents and protocols, specific pain scenarios, and discharge pain management.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | Pain Assessment & Non-Opioid Analgesics | Pain assessment scales (NRS, VAS, Wong-Baker FACES, FLACC, PAINAD); oligoanalgesia recognition and prevention; documentation requirements; acetaminophen (PO/IV adult and pediatric dosing); NSAIDs (ibuprofen, ketorolac, naproxen, diclofenac dosing table with contraindications); subdissociative-dose ketamine (IV/IN); IV lidocaine; trigger point injections; nitrous oxide |
| Part 2 | Opioid Analgesics & Regional Anesthesia in the ED | Opioid dosing tables (morphine, hydromorphone, fentanyl, oxycodone — IV, PO, IN); pediatric weight-based dosing; intranasal fentanyl via MAD device; equianalgesic conversion table; opioid prescribing best practices (PDMP, naloxone co-prescribing); risk assessment tools (ORT, STOP); ultrasound-guided nerve blocks (femoral, fascia iliaca, interscalene, serratus anterior, erector spinae, forearm, ankle, digital); local anesthetic agents comparison table; LAST protocol |
| Part 3 | Topical & Local Anesthesia and Procedural Sedation | LET gel; EMLA cream; lidocaine buffering; hematoma block; intra-articular injection; sedation continuum; pre-sedation assessment (ASA status, airway, fasting); required equipment and monitoring; sedation agents (propofol, ketamine, ketofol, etomidate, midazolam/fentanyl, nitrous oxide, dexmedetomidine) with complete dosing; ketamine-specific considerations; modified Aldrete score; recovery criteria |
| Part 4 | Specific Pain Scenarios, Discharge Management & Quality Metrics | Renal colic; fractures; headache (metoclopramide, nerve blocks); sickle cell crisis; burns; pediatric procedural pain; geriatric sedation; discharge multimodal prescribing; opioid alternatives; PDMP requirements; quality metrics and patient satisfaction |
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Renal colic, fractures, headache, sickle cell crisis, burns, pediatric procedural pain, geriatric considerations, discharge multimodal prescribing, opioid alternatives, PDMP requirements, and quality metrics.
LET gel, EMLA cream, lidocaine buffering, hematoma block, intra-articular injection, sedation continuum, pre-sedation assessment, sedation agents with complete dosing, ketamine considerations, modified Aldrete score, and recovery criteria.
Opioid dosing tables, equianalgesic conversions, intranasal fentanyl, opioid stewardship, risk assessment tools, ultrasound-guided nerve blocks, local anesthetic agents, and LAST protocol.
Pain assessment scales (NRS, VAS, FACES, FLACC, PAINAD), oligoanalgesia prevention, and first-line non-opioid analgesics including acetaminophen, NSAIDs, subdissociative ketamine, IV lidocaine, trigger point injections, and nitrous oxide.