Analgesia in the Emergency Department: A GRADE-based Evaluation of Research Evidence and Recommendations for Practice

Abstract

Emergency physicians care for patients with pain on an extremely frequent basis [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Th e prevalence of pain as the presenting complaint of patients seeking eme rgen cy department (ED) care ranges from 38 % [3] to as high as 78 % [1]. As a result, evidence-based use of analgesics should be a foundational skill of emergency physicians. However, the literature consistently reports that emergency physicians are ofte n poor at treating pain [1,2,8,13,14,16,19,20] . Notwithstanding the prevalence of pain in the ED, many patients often report that their pain was no t pr oper ly t reated [3,7,20]. I n addi tion to a compromised patient experience, sub-optimal treatment of pain will result in decreased department fl ow, increased wait times, more return visits to the ED, and increased hospitalization rates.Very few evidence-based resources and guideli nes exis t to inform emergency physicians on how to treat pain. One recent guideline on acute pain management compiled by the college of Anaesthetists of Australia and New Zealand [21] was focused primarily on treating pain perioperatively and did not include stratifi ed or graded recommendations based on the literature, highlighting the paucity of emergency medicine-specifi c guidance. Emergency physicia ns need an eff ective, evidenced-based approach to analyze and apply the options available for acute pain management.Th e objective of this article is to synthesize and evaluate the quality of medical literature surrounding analgesia delivery in the adult ED using the Grading Assessment, Development and Evaluation (GRADE) framework. We further strived to provide emergency physicians with graded recommendations upon which analgesics should be used to treat adults with acute pain in the ED. Question formulationPrior to searching the literature we developed seven clinically-oriented questions based on a scoping of the literature and a review of locally utilized ED analgesic order sets. Th is initial surveying of medical literature and our local practice environment allowed us to identify the most commonly prescribed intravenous and oral analgesics used in adult EDs in our health care region.We then used the patient-intervention-comparisonoutcome (PICO) approach to develop our seven research questions (Table 1). Th is approach has been adopted by many authors of systematic reviews and guideline panels, including the Internati onal Liaison Committee on Resuscitation (ILCOR) and the American College of Chest Physicians (ACCP) [22][23][24]. It involves identifying a specifi c population or setting to which recommen dations may be applied. Subseq uently each question compares two specifi c management strategies (intervention and comparison). Fi nally, we defi ned important patient oriented outcomes (e. g., change in pain) as well as any adverse eff ects of the medication or other safety concerns.All seven draft questions were reviewed and revised through an iterative process involving all authors. Th ese seven cl...

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Efficacy and safety of nebulized morphine given at 2 different doses compared to IV titrated morphine in trauma pain

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