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ED Opiate-Free Pain Options by Indication

Musculoskeletal Pain: Acute on Chronic Opiate-Tolerant OR Acute Opiate Naïve
No IV access - Intranasal Ketamine 50mg (0.5ml)
Acetaminophen 1000mg PO/IV
Ibuprofen 600mg PO  or Ketorolac 15mg IV/IM
Trigger Point injection - Lidocaine 1% 1-2ml subQ
Cyclobenzaprine 5mg PO or Diazepam 5mg PO/IV
Dexamethasone 8mg PO/IV
Ketamine 0.2mg/kg IV over 5-10 min
Lidoderm patch to most painful area (Max 3 patches)
Gabapentin 300mg PO (neuropathic component of pain)
Abdominal Pain
Metoclopramide 10mg IV
Diphenhydramine 25mg IV
Promethazine 25mg IV
Dicyclomine 20mg PO
Haloperidol 2.5mg IV over 5 min
Lidocaine 1.5mg/kg in 100ml NS over 10 min (Max 200mg)
Ketamine 0.2mg/kg in 50ml NS IV over 5-10 min
Sumatriptan 6mg subQ
Capsaicin 0.025% topical
Renal Colic
Acetaminophen 1000mg PO/IV
1 liter Normal Saline bolus
Ketorolac 15mg IV
Lidocaine 1.5mg/kg in 100ml NS over 10 min (Max 200mg)
Intranasal Ketamine 50mg (0.5ml)
Recurrent Primary Headache/Migraine
Acetaminophen 1000mg PO/IV
Ibuprofen 600mg PO or Ketorolac 30mg IV/IM
1 liter Normal Saline bolus
Sumartriptan 6mg subQ
Cervical or trapezius trigger point injection with Lidocaine 1% 1-2ml IM
Metoclopramide 10mg IV
Promethazine 12.5mg IV
Magnesium 1gm IV over 60 min
Valproic Acid 500mg/50ml NS IV over 20 min
Levetiracetam 1000mg/100ml NS IV over 15 min
Dexamethasone 8mg IV (migraine only)
Haloperidol 2.5mg IV over 5 min
Lidocaine 1.5mg/kg in 100ml NS over 10 min (Max 200mg)
If tension component - Cyclobenzaprine 5mg PO or Diazepam 5mg PO/IV
Extremity Fracture or Joint Dislocation
Consider regional anesthesia: e.g. nerve blocks: wrist, ankle, ulnar, radial, etc.

Immediate therapy: (steps 1-3 while setting up for block)

  • Intranasal Ketamine 50mg (0.5ml)
  • Acetaminophen 1000mg PO/IV

Followed by setting up for:

  • Ultrasound-guided regional anesthesia
    • Joint dislocation and extremity fracture
      • Lidocaine 0.5% peri-neural infiltration (Max 5mg/kg)

If unable to do ultrasound-guided regional anesthesia:

  • Ketamine 0.2mg/kg in 50ml NS over 5-10 min