Acute pain

R52.0/R52.9

DESCRIPTION

Pain that has been present for less than 4 weeks and usually occurs in response to tissue damage.

GENERAL MEASURES

  • Patient counselling.
  • Lifestyle adjustment.

MEDICINE TREATMENT

Mild pain:

Non-opioid treatment.

Non-inflammatory or post trauma:

Children

  • Paracetamol, oral, 15 mg/kg/dose 6 hourly when required. See paediatric dosing tool.

Adults

  • Paracetamol, oral, 1 g 4-6 hourly when required
    • Maximum dose: 15 mg/kg/dose.
    • Maximum dose: 4 g in 24 hours.

Pain associated with inflammation:

Adults

  • NSAIDs, e.g.:
    • Ibuprofen, oral, 400 mg 8 hourly with or after a meal.

If no relief after 2 or 3 doses, combine paracetamol and ibuprofen at the above dosages.

LoEIII [1]

Moderate pain:

If no relief to paracetamol:

ADD

Children

  • NSAIDs, e.g.:
  • Ibuprofen, oral, 5-10 mg/kg/dose 8 hourly with or after a meal. See paediatric dosing tool.
    • Discontinue if not effective after 2-3 days.

LoEIII [2]

If no response to paracetamol or ibuprofen, refer.

Adults

  • NSAIDs, e.g.:
  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal.
    • Discontinue if not effective after 2-3 days.

LoEIII [3]

If still no relief to paracetamol and ibuprofen:
ADD

  • Tramadol, oral, 50 mg, 4-6 hourly as a starting dose. (Doctor prescribed).
    • May be increased to a maximum of 400 mg daily.

Acute severe pain:

Children

Refer.

Adults

  • Tramadol, oral, 50 mg, 4-6 hourly as a starting dose (Doctor prescribed).
    • May be increased to a maximum of 400 mg daily.

AND

  • Paracetamol, oral, 1 g 4- 6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum dose: 4 g in 24 hours.

OR

  • Morphine solution, oral. (Doctor prescribed)
    • Starting dose: 10-15 mg (maximum 0.2 mg/kg) 4 hourly.
    • Elderly or frail patients: 2.5-5 mg (maximum 0.1 mg/kg) 4 hourly.

OR

  • Morphine,, IM, 10 mg, 4–6 hourly when required (Doctor prescribed)

LoEIII [4]

OR

Morphine, IV, to a total maximum dose of 10 mg. (Doctor prescribed)

  • Dilute 10 mg up to 10 mL with sodium chloride 0.9%.
  • Morphine, IV, 3-5 mg as a single dose then further boluses of 1-2 mg/minute and monitor closely.
  • Total maximum dose: 10 mg.
  • Repeat after 4 hours if necessary.
  • Monitor response to pain and effects on respiration and BP.

LoEIII [5]

Patients requiring morphine for acute pain of unknown cause or pain not responding with 1 dose must be referred for definitive treatment.

Precautions and special comments on the use of morphine

  • Morphine may cause respiratory depression. This can be reversed with naloxone. See: Exposure to poisonous substances.
    Do not administer morphine in:
    • severe head injury
    • acute asthma
    • uncontrolled hypothyroidism
  • Morphine can be used for acute abdominal pain without leading to surgical misdiagnosis.
  • Use morphine with extreme care if there is:
    • recent or concurrent alcohol intake or other CNS depressants
    • advanced chronic obstructive pulmonary disease, or other respiratory disease with imminent respiratory failure
    • hypovolaemia or shock
    • advanced liver disease
    • in the elderly

In these circumstances use:

Adults

  • Morphine, IV, to a total maximum dose of 10 mg. (Doctor prescribed)
    • Dilute 10 mg up to 10 mL with sodium chloride 0.9%.
    • Morphine, IV, 3-5 mg as a single dose then further boluses of 1-2 mg/minute and monitor closely.
    • Total maximum dose: 10 mg.
    • Repeat after 4 hours if necessary.
    • Monitor response to pain and effects on respiration and BP.

LoEIII [6]

If morphine has been administered, the time and dose should be clearly documented on the referral letter as this may alter some of the clinical features of acute abdomen or head injury.

REFERRAL

  • All children with acute severe pain.
  • No response to oral pain control and unable to initiate opioid therapy.
  • Uncertain diagnosis.
  • Management of serious underlying conditions.