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The following tick boxes  represent conclusions based on clinical experience and expert
opinion.
 A management plan for acute musculoskeletal pain should comprise the elements of
assessment (history and physical examination, but ancillary investigations are not generally
indicated), management (information, assurance, advice to resume normal activity, pain
management) and review to reassess pain and revise management plan (U).
 Information should be provided to patients in correct but neutral terms with the avoidance
of alarming diagnostic labels to overcome inappropriate expectations, fears or mistaken
beliefs (U).
 Regular paracetamol, then if ineffective, NSAIDs, may be used for acute musculoskeletal
pain (U).
 Oral opioids, preferably short‐acting agents at regular intervals, may be necessary to
relieve severe acute musculoskeletal pain; ongoing need for such treatment requires
reassessment (U).
 Adjuvant agents such as anticonvulsants, antidepressants and muscle relaxants are not
recommended for the routine treatment of acute musculoskeletal pain (U).

9.6 ACUTE MEDICAL PAIN

9.6.1 Acute abdominal pain
Acute abdominal pain may originate from visceral or somatic structures or may be referred;
neuropathic pain states should also be considered. Recurrent acute abdominal pain may be a
manifestation of a chronic visceral pain disorder such chronic pancreatitis or irritable bowel
syndrome and may require a multidisciplinary pain management approach.
Analgesia and the diagnosis of acute abdominal pain.
A common misconception is that analgesia masks the signs and symptoms of abdominal
CHAPTER 9 form of opioids), does not interfere with the diagnostic process in acute abdominal pain in
pathology and should be withheld until a diagnosis is established. Pain relief (usually in the

adults (Manterola et al, 2007 Level I) or in children (Kim et al, 2002 Level II; Green et al, 2005 Level II),
or lead to increased errors in clinical management (Ranji et al, 2006 Level I).
Renal colic
NsNSAIDs, opioids (Holdgate & Pollock, 2005 Level I) and metamizole (dipyrone) (Edwards,
Meseguer et al, 2002 Level I) provided effective analgesia for renal colic. NsNSAIDs reduced
requirements for rescue analgesia, produced less vomiting than opioids (particularly pethidine
[meperidine] (Holdgate & Pollock, 2005 Level I) and reduced the number of episodes of renal
colic experienced before passage of the renal calculi (Kapoor et al, 1989 Level II; Laerum et al,
1995 Level II).
Onset of analgesia was fastest when nsNSAIDs were administered intravenously (Tramer et al,
1998 Level I) although suppositories were also effective (Lee et al, 2005 Level II). A combination
of IV ketorolac and morphine provided a greater reduction in pain scores, earlier onset of
complete pain relief and a reduced need for rescue analgesia, compared with using either
analgesic alone (Safdar et al, 2006 Level II).

250 Acute Pain Management: Scientific Evidence