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Fractured neck of femur
In patients with a fractured neck of femur in the emergency department, a ‘3 in 1’ femoral
nerve block with bupivacaine, combined with IV morphine was more effective than IV
morphine alone, with a faster onset of analgesia (Fletcher et al, 2003 Level II). A facia iliaca block
with mepivacaine, significantly improved pain scores and reduced IV morphine requirements
and sedation, compared with IM morphine (Foss et al, 2007 Level II). For safety reasons,
ropivacaine or levobupivacaine may be the preferred local anaesthetics (see Section 5.1).
Wounds
Local anaesthesia is frequently required for the treatment of wounds in the emergency
department. Agents most commonly used for needle infiltration are lignocaine or longer
acting agents such as ropivacaine or levobupivacaine, depending on the duration of
anaesthesia required and whether analgesia following the procedure is desirable.
It is less painful to infiltrate local anaesthesia by injection through the wound rather than
in the tissues surrounding it (Bartfield et al, 1998 Level II; Kelly et al, 1994 Level III‐1). There are
conflicting data on whether buffering of lignocaine reduces the pain of infiltration (Boyd, 2001
Level II).
Digital nerve block with 0.75 % ropivacaine, significantly prolonged analgesia and reduced
rescue analgesia requirements to 24 hours, without a clinically significant increase in time to
block onset, compared with 2% lignocaine (Keramidas & Rodopoulou, 2007 Level II).
Topical local anaesthesic preparations are also used, particularly for wound care in children.
Topical tetracaine, liposome‐encapsulated tetracaine, and liposome‐encapsulated lignocaine
are as effective as EMLA cream for dermal instrumentation analgesia in the emergency
department (Eidelman et al, 2005 Level I). Topical anaesthetic preparations such as mixtures of
adrenaline, lignocaine and amethocaine are effective alternatives to infiltration with local
anaesthesia for simple lacerations (Smith et al, 1997 Level II; Singer & Stark, 2000 Level II) and
reduced the pain of infiltration when injecting local anaesthetics (Singer & Stark, 2000 Level II).
Topical lignocaine and adrenaline applied to a wound in sequential layers, significantly
reduced reports of pain during initial application, compared with a 2% lignocaine injection,
but with no difference in pain scores during suturing (Gaufberg et al, 2007 Level II). A topical gel
dressing containing morphine was no more effective than other gel dressings in reducing
burns injury pain in the emergency department (Welling, 2007 Level II).

9.9.3 Non-pharmacological management of pain CHAPTER 9

Although analgesic agents may be required to treat pain in the emergency department setting,
the importance of non‐pharmacological treatments should not be forgotten. These include ice,
elevation and splinting for injuries and explanation of the cause of pain and its likely outcome
to allay anxiety. Psychological techniques such as distraction, imagery or hypnosis may also be
of value (see Sections 8.1 and 9.3.2).
Deep breathing exercises did not provide effective pain relief to patients in emergency
departments (Downey & Zun, 2009 Level II).

Acute pain management: scientific evidence 293