Acute Pain Relief Research Articles

Vertebral osteoporotic fractures: differential diagnosis, therapeutic approaches

Osteoporotic vertebral fractures (OVF) are a severe complication of osteoporosis associated adverse outcomes, acute and chronic pain syndrome. If vertebral fractures (deformities) are detected, osteoporosis is diagnosed regardless of bone mineral density and the 10-year absolute fracture risk scale of the Fracture Risk Assessment Tool, but subject to the exclusion of other metabolic osteopathies. The article presents differential diagnosis of OVF with osteopathies such as osteomalacia, tumors or metastatic lesions of the spine, Paget»s disease, myeloma, hyper parathyroid osteodystrophy, post-traumatic vertebral deformities, Scheuermann-Mau disease. Differential diagnosis between different types of osteopathies is based on features of the clinical picture, history, changes in laboratory parameters (calcium, phosphorus, alkaline phosphatase, parathyroid hormone, vitamin D3 and on data from X-ray of the skeleton examination. It is necessary to take into account conditions under which the vertebral fracture occurred, its localization, prevalence, peculiarities of changes in bone structures, presence or absence of osteoporotic background, degenerative-dystrophic changes in the spine. The tactics of managing the patients with OVF is determined by the time after the fracture, its severity, nature of the pain syndrome and includes non-drug and medical measures. Among non-pharmaceutical measures in the acute period of OVF, there are unloading of the spinal column, use of a corset, and physical therapy. Medical measures are aimed at pain relief using injectable and oral forms of nonsteroidal anti-inflammatory drugs, central acting muscle relaxants and anti-osteoporotic therapy. Dexketoprofen (Dexalgin) is the first-line drug for relief of acute pain in OVF which has a rapid and pronounced analgesic effect. For the anti-osteoporotic therapy, the drugs of choice are parenteral bisphosphonates, denosumab and teriparatide.

Neuroapraxia of Trigeminal Nerve Controlled by Neuromonitoring During Microvascular Decompression in Multiple Sclerosis Patients Affected by Drug-Resistant Trigeminal Neuralgia Recurrent After Previous Operations

BACKGROUND AND IMPORTANCE: Trigeminal neuralgia (TN) can complicate the clinical course of multiple sclerosis (MS) and can be very difficult to treat. Usually, these patients experience multiple recurrences after surgical procedures with a poor overall outcome. To the best of our knowledge, we report the first 3 cases of drug-resistant MS-related TN recurrent after previous operations in which intraoperative neuromonitoring controlled neuroapraxia of trigeminal nerve was performed. We describe the surgical technique, report the clinical outcomes of patients, and review the pertinent literature. CLINICAL PRESENTATION: Neuroapraxia of trigeminal nerve was conducted using a standard straight Yasargil temporary titanium aneurysm clip on the main trunk of the trigeminal nerve. Trigeminal somatosensory evoked potentials and cortico-bulbar motor evoked potentials registered from trigeminal and facial nerves were recorded during the procedure. The trigeminal nerve clipping was conducted for a maximum of 30 seconds or less in the case of a decrease in neurophysiological responses. The preoperative Barrow Neurological Institute score was V, IV, and IV for the 3 patients, respectively. We obtained acute pain relief in all patients after the procedure. All patients had a Barrow Neurological Institute I at the latest follow-up (10, 10, and 9 months, respectively). No complications were reported postoperatively and at follow-up. CONCLUSION: Intraoperative neuromonitoring controlled neuroapraxia of trigeminal nerve with temporary titanium aneurysm clip application during microvascular decompression is a promising and safe procedure in MS patients with recurrent MS-related TN. Further studies with longer follow-up are needed to confirm our encouraging results.

Repetitive daily oxytocin treatment reduces weight gain but not acute neonatal procedural pain.

While the incidence of neonatal intensive care unit (NICU) admission steadily increases, neonatology lacks evidence of a safe, effective, and preventive analgesic for treating procedural pain. Given its role in nociception and promoting healthy neurodevelopment, the endogenous neuropeptide oxytocin (OT) emerges as a promising candidate. This study investigates the use of daily repeated subcutaneous OT (1 mg/kg) treatment in an established model of neonatal repetitive procedural pain and assesses the effectivity of OT treatment on mechanical sensitivity and body weight. Contrary to our hypothesis repeated daily OT treatment did not prevent the development of mechanical hypersensitivity following needle pricks. Furthermore, treatment with OT diminished body weight gain in neonatal pups, a major side effect observed throughout the neonatal week. These results highlight the unique nature of the maturing nociceptive system that makes the identification and selection of analgesic options for the treatment of acute neonatal procedural pain a major challenge. In conclusion, our preclinical results do not support the use of repeated OT for acute pain relief in the NICU, and the side effects on body weight gain raise concerns about the use of OT in the NICU. Repeated daily OT treatment inhibits weight gain in neonatal rat pus. Repetitive daily OT administration does not prevent the development of mechanical hypersensitivity in a model of neonatal procedural pain. Future research must focus on the unique physiology of the developing nociceptive system to establish safe, effective and protective treatment of neonatal procedural pain.

Comparative Efficacy of Spinal Cord Stimulation in the Management of Acute Pain and Chronic Pain Related to Failed Back Surgery Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Spinal cord stimulation (SCS) is a well-established treatment for chronic pain. However, its potential in acute pain management requires further investigation. The goal of this review is to assess and compare the effectiveness of SCS for managing acute postoperative pain against chronic pain associated with failed back surgery syndrome (FBSS). A comprehensive search of databases identified randomized controlled trials (RCTs) that examined SCS for both acute and chronic pain associated with FBSS. Pain relief was measured using the Visual Analog Scale (VAS) and Numeric Rating Scale (NRS). Study quality was evaluated using the Jadad score and Cochrane risk of bias tool. Evidence suggests that SCS significantly reduces acutepain, achieving over a 50% reduction in VAS scores. For chronic pain associated with FBSS, SCS demonstrated substantial efficacy, with a mean reduction of -2.45 on pain scales compared to baseline. When compared to optimal medical management (OMM), SCS was more effective, showing a mean reduction of -1.17 in pain scores for FBSS.Overall, SCS offers significant benefits in managing chronic pain, particularly in FBSS, by reducing pain intensity and opioid use. While the initial findings for acute pain relief are promising, further high-quality RCTs are needed to better understand SCS's role in preventing the transition from acute to chronic pain. Continued research into optimizing patient selection and stimulation parameters will be essential to improve therapeutic outcomes in both acute and chronic pain management.

Less Pain, but no changes in maximal inclination angles during an overhead reach task following local anesthetic in patients with ongoing shoulder pain

This multicenter observational study aimed to assess how pain reduction, induced by local anesthesia, affects the relative angular contributions of the shoulder girdle and trunk to the maximal angular performance during a semi-constrained overhead reach task in patients with ongoing shoulder pain. Twenty-nine individuals (age 59.0 SD 12.8 years;16-male) with symptomatic shoulders were administered corticosteroid and lidocaine injections by their attending orthopedic surgeon. Immediately before and after the injections, participants reached for a target on the ceiling ten times as high as possible while their pain levels, shoulder, and trunk movements were recorded. The analysis revealed that there was a significant reduction in pain following the injections. However, there were no significant differences in maximum shoulder and trunk inclination angles between the pre- and post-injection conditions. Notably, there were slight but statistically significant alterations in humeroscapular kinematics during the initial phase of arm elevation following the injections. In conclusion, acute pain relief following local anesthetics is not associated with immediate alterations in maximum shoulder girdle and trunk inclination angles during a semi-constrained overhead reach task in patients with ongoing shoulder pain. However, there are signs of small alterations in humeroscapular kinematics during the initial phase of arm elevation.

Ultrasound-guided erector spinae plane nerve block for relief of acute cholecystitis pain

Background: Acute cholecystitis is a common surgical emergency and a painful condition that often requires frequent intravenous opioid analgesia. Sometimes, pain control of patients with acute cholecystitis is challenging. In this case, we present a potential alternative to managing acute cholecystitis pain.Case Report: A 40-year-old female presented to the ED with right upper quadrant pain. While awaiting testing and ultrasound, she received multiple doses of opioid analgesia. A point-of-care ultrasound of the right upper quadrant was performed and demonstrated findings of acute cholecystitis. Given that her pain was challenging to manage, even with intravenous opioids, an ultrasound-guided erector spinae plane (ESP) nerve block was discussed and subsequently performed at the T7 level. Thirty minutes after the procedure, the patient reported significant relief of her pain and did not require any opioid analgesia until ten hours later on the inpatient floor.Why should an emergency medicine physician be aware of this?ESP nerve blocks can potentially offer an alternative analgesic in the management of acute cholecystitis, subsequently reducing the use of opioids in the ED.ESP nerve blocks can potentially offer patients longer-lasting analgesia.ESP nerve blocks can potentially manage visceral pain in the ED.

A Preliminary Systematic Review and Meta-analysis of Randomized Control Trials of Rimegepant and Zavegepant for Acute Pain Relief from Migraine (P9-12.004)

A Preliminary Systematic Review and Meta-analysis of Randomized Control Trials of Rimegepant and Zavegepant for Acute Pain Relief from Migraine (P9-12.004)

Preoperative versus postoperative ultrasound-guided rectus sheath block for acute postoperative pain relief after laparoscopy: A retrospective cohort study.

Although rectus sheath block (RSB) is routinely used in laparoscopic surgeries to reduce mid-abdominal pain, whether RSB should be performed before or after surgery remains unclear. Herein, the optimal timing for RSB in patients undergoing laparoscopic surgery was investigated. This retrospective cohort study analyzed the data of patients who underwent RSB during laparoscopic procedures at our hospital between January 2013 and December 2018. The primary outcome was the time to rescue analgesia within 24 hours postanesthesia. The patients were divided into preoperative (pre-) and postoperative (post-) RSB groups. A multivariable Cox proportional hazards regression model was used to analyze the time to rescue analgesia in the unmatched and propensity score (PS)-matched patient populations. In total, 609/14,284 patients were included (pre-RSB group, 227 patients; post-RSB group, 382 patients). After PS matching, 97 patients were assigned to both groups. Although the time from extubation to the first analgesic request was not significantly different between the 2 groups (322 vs 294 minutes, P = .57), the patients in the pre-RSB group showed a lower risk of postoperative first analgesic administration after PS matching (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .023). Among patients undergoing laparoscopic surgery, those in the pre-RSB group tended to have a longer time to the first analgesic request and had a lower risk of analgesic administration within the first 24 hours than those in the post-RSB group. Thus, performing RSB preoperatively may be preferable.

Efficacy of quadratus lumborum block in the treatment of acute and chronic pain after cesarean section: A systematic review and meta-analysis based on randomized controlled trials.

This analysis aimed to explore the analgesic effects of quadratus lumborum block on acute and chronic postoperative pain among patients undergoing cesarean section. PubMed, Cochrane, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and VIP databases for Randomized Controlled Trials (RCTs) that focused on the use of quadratus lumborum block in cesarean section procedures were searched from the inception of the databases until December 2022. Studies were screened based on inclusion and exclusion criteria, and were then conducted for quality assessment and data extraction. Meta-analysis was performed using Stata 15.0 software. Two researchers independently screened the studies, extracted data, and evaluated the risk of bias for the included studies. In case of any disagreements, it was resolved by consultation with a third party opinion. A total of 21 studies involving 1976 patients were finally included, with an overall acceptable study quality level. Compared to the control group, the administration of Quadratus Lumborum Block (QLB) resulted in significant reduction in the postoperative 24-hour visual analog scale (VAS) score (WMD = -0.69, 95% CI: -1.03 ~ -0.35, P < .001) and the consumption of opioid analgesics within 24 hours after surgery (WMD = -2.04, 95% CI: -2.15 ~ -1.92, P = .002). The incidence of chronic pain 3 months QLB (OR = 0.41, 95% CI: 0.09 ~ 1.88, P = .253) and 6 months (OR = 0.83, 95% CI: 0.33 ~ 2.07, P = .686) after surgery were observed to increase as compared with the control group. The use of QLB for postoperative analgesia after cesarean section, particularly in the relief of acute postoperative pain, had been proven to significantly decrease the VAS score and morphine consumption within the first 24 hours after surgery. However, further studies are needed to determine its impact on managing chronic postoperative pain.

Assessment of the Therapeutic Potential of Nimbadi Churna and Kokilakshadi Kwath in Managing Vatarakta (Gout): A Randomized Comparative Clinical Study

The rise in hyperuricemia, often linked to changing dietary habits, has increased the global prevalence of gout, affecting 2.1 million people with a prevalence of 0.2-0.6%. Gout is indicative of underlying comorbidities such as obesity, diabetes, hypertension, and renal diseases. In contemporary medicine, Vatarakta is likened to gout due to shared causes and symptoms, involving the vitiation of Vata and Rakta by distinct etiological factors, and the restricted movement of vitiated Vata by vitiated Rakta leads to Vatarakta. While asymptomatic hyperuricemia may not necessitate intervention, clinically manifest gout requires long-term treatment to lower uric acid levels and acute pain relief. Current medications like allopurinol, uricosuric agents, NSAIDs, colchicine, and glucocorticosteroids carry mild to severe side effects. Recognising the need for an effective, affordable, and well-accepted treatment. The study assessed the efficacy of Nimbadi Churna and Kokilakshadi Kashay in managing Vatarakta through an open, randomized clinical trial with 60 patients. Both treatments were administered for 28 days. Dosages were 3gm B.I.D for Nimbadi Churna and 40ml B.I.D for Kokilakshadi Kashay. Four follow-ups were performed every 7th day, assessing subjective parameters via grade scores and serum uric acid levels. Results indicated both treatments were significantly effective (p&lt;0.001), with no statistical difference between them (p&gt;0.05). Nimbadi Churna and Kokilakshadi Kashay demonstrated notable efficacy in Vatarakta management, presenting promising alternatives with minimal complications. While further research is necessary for validation, these findings highlight the promise of Ayurvedic approaches in the comprehensive management of gout.

Management of acute pain in an outpatient setting

The management of acute pain focuses on a multimodal approach integrating both pharmacological and non-pharmacological treatments. In recent years, caution towards opioids has increased, with several studies showing that they are not necessarily more effective than non opioid analgesics for pain relief for musculoskeletal pain, which is the most common painful symptom in outpatient settings, and have the disadvantages of more side effects and a risk of dependence. Adjuvant and non-pharmacological treatments (e.g. manual medicine, acupuncture, hypnosis) are gaining importance to reduce therapeutic escalation and improve pain management. This approach which can be more personalized, aims to minimize risks while ensuring effective relief of acute pain.

Unraveling the parameters and biological mechanisms of CO2 laser therapy for acute pain relief.

Acute pain-related pathology is a significant challenge in clinical practice, and the limitations of traditional pain-relief drugs have made it necessary to explore alternative approaches. Photobiomodulation (PBM) therapy using CO2 laser has emerged as a promising option. In this study, we aimed to identify the optimal parameters of CO2 laser irradiation for acute pain relief through in vivo and in vitro experiments. First, we validated the laser intensity used in this study through bone marrow mesenchymal stem cells (BMSCs) experiments to ensure it will not adversely affect stem cell viability and morphology. Then we conducted a detailed evaluation of the duty cycle and frequency of CO2 laser by the hot plate and formalin test. Results showed a duty cycle of 3% and a frequency of 25 kHz produced the best outcomes. Additionally, we investigated the potential mechanisms underlying the effects of CO2 laser by immunohistochemical staining, and found evidence to suggest that the opioid receptor may be involved in its analgesic effect. In conclusion, this study provides insights into the optimal parameters and underlying mechanisms of CO2 laser therapy for effective pain relief, thereby paving the way for future clinical applications.

Effectiveness of Intranasal Analgesia in the Emergency Department.

In the Emergency Department (ED), pain is one of the symptoms that are most frequently reported, making it one of the most significant issues for the emergency physician, but it is frequently under-treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondly, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a narrative review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library, and Controlled Trials Register, finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia, showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. Intravenous is simple to administer, non-invasive, rapid onset, and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management.

Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis.

Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.

(011) Using Pre-Operative Low Intensity Vestibular Shockwave Therapy Reduces Opioid Use Post-Vestibulectomy

Abstract Introduction Surgeons performing complete vestibulectomy for neuro-proliferative vestibulodynia need to consider two competing post-operative interests: accomplishing acute pain relief in the early postoperative period; reducing risks of persistent post-operative opioid use. Data support that measures to decrease overall post-operative opioid use will decrease future opioid-related adverse events including opioid abuse and addiction. Sexual medicine providers are thus motivated to identify strategies such as pre-operative low intensity shockwave therapy (LISWT) to decrease opioid use in these vestibulectomy patients. To date, only one study has been published assessing the effect of pre-operative LISWT on surgical outcome. Dumfarth at al reported in a prospective randomized study that pre-operative LISWT significantly improved lower extremity wound healing compared to controls in patients undergoing vein harvesting for coronary artery bypass graft surgery. While Dumfarth et al did not directly assess post-operative pain, pre-operative LISWT was associated with statistically significantly increased satisfactory healing, reduced disturbance of healing and reduced minor skin infections, all consistent with less post-operative pain. It was hypothesized that pre-operative LISWT improved wound healing via enhanced blood supply and angiogenesis through expression of vascular endothelial growth factor (VEGF) and nitric oxide synthesis, and via anti-inflammatory action downregulating necrosis factor B activation thereby lowering inflammatory cytokines. Objectives We wished to see if pre-operative LISWT would reduce opioid use in women undergoing complete vestibulectomy. The objective of this study was to compare the use of opioids following vestibulectomy when LISWT with Urogold 100™ MTS was applied just prior to surgery versus no shockwave. LISWT is a non-invasive, non-pharmacologic, non-surgical treatment strategy with low morbidity that is FDA-cleared for pain amelioration in the US as non-significant risk in humans, Urogold 100™MTS provides unfocused electrohydraulic shockwaves with a unique parabolic reflector. Methods Patients scheduled for surgery were required to present to the hospital 4 days before surgery for a COVID-19 test. On that day and each subsequent day until surgery, based on the patient’s availability, the patient presented to the office for approximately 2400 shocks to the vestibule. This is a descriptive study of the patients’ post-operative experiences with pain. Results To date 4 women have undergone LISWT just prior to surgery. At the time of surgery Exparel was delivered to the site, allowing them 24-36 hours of anesthesia to the area so they could travel home easily. Patients were prescribed Percocet to be take every 4 hours as needed. Post-op patients routinely use this opioid 4-6 times a day for multiple days, causing constipation among the many side effects. The women who underwent LISWT immediately prior to surgery have experienced decreased levels of pain post-operatively such that they are using ½ tab of Percocet at bedtime or twice a day, thus decreasing opioid use with all of its potential side effects. Conclusions Performing LISWT using Urogold 100™MTS may reduce the need for opioid medications after total vestibulectomy with vaginal advancement flap as it may mediate pain after the surgical procedure. Disclosure No.

Prevalence and Persistence of Prescription Opioid Use Following Hospital Discharge After Childbirth: An Australian Population-Based Cohort Study.

Opioid analgesics are used for acute postpartum pain relief but carry risks, including persistent long-term opioid use. Our primary objective was to estimate the prevalence of persistent use following hospital discharge after childbirth. We conducted a population-based cohort study of women discharged from public or private hospitals in New South Wales, Australia, between 2012 and 2018 following vaginal birth (VB) or cesarean delivery (CD). We used linked hospitalization and medicine dispensing data to calculate the prevalence of opioid use within 14 days of hospital discharge for childbirth using an external estimate of the total number of hospital admissions for childbirth per year as the denominator. Among women dispensed an opioid postdischarge, we estimated the prevalence of persistent use defined as ≥3 dispensings between 30- and 365-days postdischarge. To calculate the odds of persistent opioid use, we performed a series of logistic regressions each including a single characteristic of interest. Included characteristics were maternal and birth characteristics, maternal medical conditions, prior use of certain medicines, and the initial opioid dispensed following discharge for childbirth. The final cohort comprised of 38,832 women who were dispensed an opioid in the 14 days following discharge after childbirth. Between 2012 and 2018, the prevalence of opioid use was increased following CD (public hospital 16.6%-21.0%; private hospital 9.8%-19.5%) compared with VB (public hospital 1.5%-1.5%; private hospital 1.2%-1.4%) and was higher following discharge from public hospitals compared with private. The most commonly dispensed opioids following discharge for childbirth were oxycodone (44.8%; 95% confidence interval [CI], 44.3-45.3), codeine (42.1%; 95% CI, 41.6-42.6), and tramadol (12.9%; 95% CI, 12.6-13.2). Among women dispensed an opioid, the prevalence of persistent opioid use was 5.4% (95% CI, 5.1-5.6). This prevalence was 11.4% (95% CI, 10.5-12.3) following a VB as compared with 4.3% (95% CI, 4.1-4.6) among those who underwent a CD ( P < .001). Characteristics associated with persistent opioid use included smoking during pregnancy, age <25 years, living in remote areas, discharged from a public hospital, history of opioid use disorder, other substance use disorder, mental health diagnosis, or prior use of prescription opioids, nonopioid analgesics, or benzodiazepines. The results of this cohort study indicate that Australian women have a higher prevalence of opioid use following CD compared to VB. One in 19 women dispensed an opioid postdischarge used opioids persistently. Careful monitoring of opioid therapy following childbirth is warranted, particularly among women with characteristics we identified as high risk for persistent opioid use.

Safety and Efficacy of Low-Dose Versus High-Dose Parenteral Ketorolac for Acute Pain Relief in Patients 65 Years and Older in the Emergency Department.

Background There is limited data surrounding acute pain management in elderly ED patients. Ketorolac is a potent non-steroidal anti-inflammatory drug (NSAID) with dose/duration-dependent side effects. There is evidence that an analgesic ceiling effect exists for parenteral ketorolac doses greater than 10 milligrams (mg); however, this has not been studied in patients 65 years and older. Methods This was a retrospective chart review of ED patients 65 years and older who received at least one dose of parenteral ketorolac. Patients were separated into two cohorts based on the ketorolac dose received: 15 mg IV or 30 mg intramuscular (IM) and 30 mg IV or 60 mg IM. The primary objective was to evaluate the analgesic efficacy of parenteral ketorolac doses measured as needing rescue analgesia from 30 minutes to 2 hours after ketorolac administration. Secondary objectives included changes in pain scores and the occurrence of adverse drug events commonly associated with ketorolac. Results Two-hundred and sixty patients received ketorolac doses of 15 mg IV or 30 mg IM, and 52 received 30 mg IV or 60 mg IM. The primary outcome occurred in seven of 52 patients who received ketorolac 30 mg IV or 60 mg IM and 17 of 260 patients who received ketorolac 15 mg IV or 30 mg IM (13.5% vs. 6.5%, p=0094; OR: 2.22, 95% CI: 0.87-5.67). The average change in pain scores were 2.9 (±3.1) and 2.8 (±2.9) for patients who received doses 30 mg IV or 60 mg IM compared to doses 15 mg IV or 30 mg IM, respectively (p=0.154). The occurrence of adverse events was low in both groups. Conclusion Parenteral ketorolac doses of 15 mg IV or 30 mg IM did not demonstrate a greater need for rescue analgesia compared to doses of 30 mg IV or 60 mg IM.

Pediatric Migraines: A Comprehensive Review and Perspectives on Diagnosis and Treatment.

Pediatric migraine (PM) is one of the most prevalent neurological disorders in children. It has numerous variants and the sufferers often present to emergency departments with a wide variety of signs and symptoms that make diagnosis difficult. The trend in diagnosing and managing PM cases remain suboptimal despite the comprehensive diagnostic criteria and various therapeutic options. In this review, we discuss PM, provide an approach to the diagnosis, and describe the various available management options. However, the diagnosis of migraine is based on history and physical examination; no specific diagnostic test is available. The main management aspects are acute pain relief, prevention, and identifying triggering factors.

Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain

Ketorolac is a commonly used nonopioid parenteral analgesic for treating emergency department (ED) patients with acute pain. Our systematic review aims to summarize the available evidence by comparing the efficacy and safety of differing ketorolac dosing strategies for acute pain relief in the ED. The review was registered on PROSPERO (CRD42022310062). We searched MEDLINE, PubMed, EMBASE, and unpublished sources from inception through December 9, 2022. We included randomized control trials of patients presenting with acute pain to the ED, comparing ketorolac doses less than 30 mg (low dose) to ketorolac doses more than or equal to 30 mg (high dose) for the outcomes of pain scores after treatment need for rescue analgesia, and incidence of adverse events. We excluded patients in non-ED settings, including postoperative settings. We extracted data independently and in duplicate and pooled them using a random-effects model. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool and the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach. This review included 5 randomized controlled trials (n=627 patients). Low-dose parenteral ketorolac (15 to 20 mg), as compared to high-dose ketorolac (≥30 mg), probably has no effect on pain scores (mean difference 0.05 mm lower on 100 mm visual analog scale, 95% confidence interval [CI] -4.91 mm to+5.01 mm; moderate certainty). Further, low-dose ketorolac at 10 mg may have no effect on pain scores compared to high-dose ketorolac (mean difference 1.58 mm lower on 100 mm visual analog scale, 95% CI -8.86 mm to+5.71 mm; low certainty). Low-dose ketorolac may increase the need for rescue analgesia (risk ratio 1.27, 95% CI 0.86 to 1.87; low certainty) and may have no difference on rates of adverse events (risk ratio 0.84, 95% CI 0.54 to 1.33; low certainty). In adult ED patients with acute pain, parenteral ketorolac given at doses of 10 mg to 20 mg is probably as effective in relieving pain as doses of 30 mg or higher. Low-dose ketorolac may have no effect on adverse events, but these patients may require more rescue analgesia. This evidence is limited by imprecision and is not generalizable to children or those at higher risk of adverse events.

Effects of a novel acetaminophen (APAP) analog on survival time after extremity trauma and moderate or severe conscious hemorrhage in rats

Background: Multiple analgesics are used for acute pain relief following trauma in both the military and civilian settings. However, in addition to their ability to relieve pain, medical providers must also be concerned about secondary effects of the analgesics, especially effects on the cardiovascular and respiratory systems when the pain of trauma is associated with hemorrhage. Kalyra Pharmaceuticals has developed novel analogs of APAP to circumvent liver toxicity and improve analgesic efficacy. These analogs have the potential to replace opioids for severe pain while minimizing adverse effects. The objective of this study is to test a pain-reducing dose of D-112, an APAP analog, for its effects on survival to hemorrhage after extremity trauma (ET). We hypothesize that D-112 will not affect survival after either moderate or severe hemorrhage. Methods: Male Rats (~360 grams) were randomly assigned to receive either 0.9% saline (V) or 50 mg/kg D-112 (D) after either ~37% or ~50% of blood volume hemorrhage. All rats were surgically implanted with a carotid catheter under anesthesia. Carotid catheters were used for blood withdrawal and for injection of V or D. 24 hrs later, rats were briefly (~10 min) anesthetized again and ET consisting of soft tissue injury (crushing of the right gastrocnemius and semimembranosus muscles for 30 sec with forceps) and fibula fracture was performed. After completion of ET, rats were allowed to recover. 90 min after ET, rats underwent a conscious hemorrhage via the indwelling catheter. At the end of hemorrhage, rats received either V or D via the carotid catheter. Rats were observed for a maximum of 4 hrs after the start of the 25 min hemorrhage. Results: Survival after hemorrhage was recorded in the 4 groups: V-37% (n=13), D-37% (n=11), V-50% (n=10), D-50% (n=11). The survival proportions at 240 min were 92.3% for V-37%, 81.8% for D-37%, 60.0% for V-50%, and 18.1% for D-50%. While there was no significant difference in the survival curves of V-37% and D-37%, the survival curves of V-50% and D-50% were significantly different ( p = 0.036). Conclusions: The analgesic dose of D-112 tested decreased survival after ET and severe hemorrhage (~50% of blood volume), but not after ET and moderate hemorrhage (~37%). These results suggest that D-112 may not be an appropriate analgesic following traumatic hemorrhage. Applied Pain Research Program, US Army Clinical and Rehabilitative Medicine/Joint Program Committee 8, and US Army Combat Casualty Care Research Program, US Army Medical Research and Development Command. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.