Painful to think about? Assessment and Management of Pain in the ED

Authors: Liz Herrieven, Charlotte Davies / Editor: Liz Herrieven / Reviewer: Charlotte Davies / Codes: / Published: 21/02/2023 / Reviewed: 05/08/2025

Pain is probably the most common reason for people to attend the Emergency Department (ED). It should be our bread and butter, as Emergency Physicians. Getting it right isnt easy though. Not only are there the physical causes to unpick, but also the impact of psychological, cultural and contextual influences to trip us up. Time and again, the RCEM national audits, and more recently quality improvement projects, have shown that, when managing children in pain, emergency departments are consistently poor at assessing and treating pain, reassessing and responding to that reassessment.1

With regards to children, some of this will be to do with our lack of confidence when assessing pain in pre-verbal or non-verbal children. Its much easier to recognise someone is in pain when they say, Oh doctor, this is rather painful, you know. Some of our poor performance will also be to do with reluctance to use strong analgesics in children, for fear of causing side effects. It is true that, for those more used to managing adults, many medications are less predictable in children, who may, depending on their age and weight, have different liver or renal metabolism, have smaller fat stores or a larger body weight percentage of water, for example. But we still have a duty to manage pain appropriately, whatever the age of our patients.

There is nothing that defines medicine more than the need to make it better, and so, nailing analgesia is such a fundamental part of being a practitioner, especially in children.

But the experience of pain is different for different patients, with the exact same situation, and changes depending on what they have presented with.

To properly look after them, we need to tailor our technique to:

  1. Royal College of Emergency Medicine. Pain in Children. National Quality Improvement Project. National Interim Report 2020/21. Jan 2022.
  2. Distress and Discomfort Assessment Tool (DisDAT). St Oswald’s Hospice.
  3. Paediatric Pain Profile (PPP).
  4. Liz Herrieven, Erica Donovan and Tara McCormack . Hospital Passports, Don’t Forget the Bubbles, 2021.
  5. Carley S. Please Use Less Ketamine LAT Gel At St.Emlyns, 2012.
  6. Lloyd G. Pain Management in Adult Patients. RCEMLearning. Updated in 2023

Remember how useful nerve blocks, local anaesthetics and topical treatments such as LAT gel5 can be, and use these alongside your traditional analgesia.

Step Zero Directed Analgesia See table above
Step One Paracetamol There is no evidence IV works any more effectively or quicker than PO. IV is more expensive. Dont forget PR as an option.
Step Two NSAIDs
Ibuprofen, Diclofenac		 See BNF. Always start with ibuprofen as least cardio-toxic. Evidence around bigger doses being more effective is conflicting – but anecdotally bigger doses are probably better. PR diclofenac useful in renal colic.
Step Three Weak Opiates Codeine should never be used for headaches, should be carefully considered in the elderly and never used in children. It should never be given as a sole agent – give with paracetamol.
60mg is not significantly more effective than 30mg but has considerable side effects.
Tramadol should only be given if the patient is on it already- its a horrible drug.
Codeine and tramadol should never be given in combination.
Step Four Nefopam Consider it carefully – it shouldnt be used lightly, especially in the elderly. But works well. Not used for children.
Step Five Strong Opiates
Morphine – PO, SC, IM or IV
Oxycodone
Fentanyl, diamorphine		 Oral is often preferable and works in about 30min. IV peaks in 20min.
Oxycodone is better for adults with renal impairment.
Intranasal fentanyl or diamorphine are fast-acting and can help avoid needles in children.
Step Six Neuropathic Agents
Gabapentin, amitriptyline		 These take a while to work and should not be initiated in the emergency department.

Analgesic Ladder

When it comes to perception and modulation of pain, then keeping calm, being reassuring and giving clear explanations are all key. For children, distraction can be great. For adults, distraction can also be great, but might be more along the lines of chatting and putting them at ease, rather than blowing bubbles. For adolescents, let them have their social media fix. Dont forget to also keep parents and carers calm as anxiety is truly infectious.

Analgesia

Provide analgesia or pain relief rather than pain killers (theyre a nocebo).

Be positive in your belief of their effectiveness.

Consider directed or general analgesics and dont forget adjuncts such as LAT gel or nerve blocks.

Breathing
    • Square or Rectangular breathing
    • Circular breathing – imagine breath flows up one side of their body as you breathe in, and down the other side of the body as you breathe out.
    • Purifying breathing – imagine the body is surrounded by a pleasant light or colour. As they breathe in, imagine sending that light or colour all throughout the body. As they breathe out, they can breathe out any feelings of discomfort, tension or fear.

Breathing image
Comfort
    • Ask for a comfort score
    • Be truthful but reassuring. Remember pain is compounded by anxiety and fear – the emotional component. Change the focus away from the pain – ask for comfort scores not pain scores, ask what they like doing when theyre not in the hospital.
    • Avoid nocebo
    • Saying something like:
      Are you familiar with mental imagery and how it can redirect biochemical processes? Whilst we’re waiting for the treatment to work, we can enhance the healing process, and help your body respond to the treatment. I wonder if youd like to close your eyes, and as you do, notice the immediate increase in comfort. Now, just allow that feeling of increased comfort to increase even more. As it does, notice you are beginning to relax the muscles around your abdomen a little more, and that this also increases the sense of comfort. Good.
Distract Change the focus from the discomfort. Provide a task. As you lie comfortably here, plan what youre going to do in the future when youre comfortable.
For more details and resources on these techniques, take a look at the Handbook of Communication in Anaesthesia & Critical Care: A Practical Guide to Exploring the Art by Allan Cyna et al. and consider the RCoA toolkit on preparing your mind – many transferrable skills.

The ABCD of Pain Management

Once youve done your best to manage your patients pain, dont stop there. Reassess and respond to that reassessment. If they are still in pain, or the pain returns, you still have work to do.

Managing pain not only helps our patients thats probably why theyre in the ED, after all but it can give us great job satisfaction, and thats always worth having.

References

  1. Royal College of Emergency Medicine. Pain in Children. National Quality Improvement Project. National Interim Report 2020/21. Jan 2022.
  2. Distress and Discomfort Assessment Tool (DisDAT). St Oswald’s Hospice.
  3. Paediatric Pain Profile (PPP).
  4. Liz Herrieven, Erica Donovan and Tara McCormack . Hospital Passports, Don’t Forget the Bubbles, 2021.
  5. Carley S. Please Use Less Ketamine LAT Gel At St.Emlyns, 2012.
  6. Lloyd G. Pain Management in Adult Patients. RCEMLearning. Updated in 2023

Remember how useful nerve blocks, local anaesthetics and topical treatments such as LAT gel5 can be, and use these alongside your traditional analgesia.