Other Painful Presentations


There is a limited evidence base for the management of pain in burn injuries5.

Cooling the burn immediately after injury is a first aid measure that limits injury and provides relief.

On presentation to the emergency department (ED) you should aim to assess the depth and size of burn on designated charts promptly, so as to allow the burn to be covered (Clingfilm, Jelonet), an analgesic manoeuvre in itself.

Titrated intravenous morphine is otherwise the key. Paracetamol and ibuprofen may reduce opiate requirements.

Sickle cell crises

Titrated IV morphine is recommended with, ideally, patient controlled analgesia thereafter. Under prescribing in young black males may be a real issue.

Supplemental oxygen has not been shown to decrease the pain or duration of a crisis5.

Single dose parenteral ketorolac does not reduce opiate requirements5.

A Cochrane review confirms that parenteral corticosteroids shorten the period of analgesic requirement and hospital length of stay in a sickle cell crisis.


Adult Pain Mgt27

Fig 19 Migraine a possible cause

Triptans are highly effective in the treatment of severe acute migraine where simple analgesia has failed.

Subcutaneous injections and nasal sprays provide the fastest symptom relief and higher efficacy, particularly in the presence of nausea and vomiting.

Oral triptans are better tolerated but take longer to act and are less reliable5.

Parental metoclopramide, chlorpromazine and prochlorperazine are also effective treatments in the ED. Opiates have limited benefit and their use is not recommended5.

Cluster headaches

Adult Pain Mgt28

Fig 20 Cluster headaches a possible cause

Cluster headaches are associated with dilation of blood vessels and inflammation of nerves behind the eye.

Subcutaneous sumatriptan injection and intranasal sumatriptan spray are effective.

Oxygen therapy, 7-10 L/min for 15 minutes can be used alternatively, or in addition5.

Pain out of proportion

Adult Pain Mgt29

Fig 21 Fractured tibia complicated by compartment syndrome


Compartment syndrome may complicate injuries of the forearm, foot, thigh, upper arm and indeed abdomen, as well as a fractured tibia.

A Lisfranc injury (fracture/dislocation of the midfoot) is an important injury that might be overlooked on traditional x-rays. Clue: excessive pain. Ask for a lateral foot x-ray to aid your diagnosis.

Painful +++ cellulitis? Think necrotising fasciitis.