Acute Pain
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Please click on the link below to access the most up-to-date version of this guideline. The content on this page is currently being updated to align with the latest publication. Always check the version number at the bottom of the screen to confirm which version you are using.
R52.0/R52.9
DESCRIPTION
Acute pain happens suddenly, starts out sharp or intense, and serves as a warning sign of disease or threat to the body. It is caused by injury, surgery, illness, trauma, or painful medical procedures and generally lasts from a few minutes to less than six months. Acute pain usually disappears whenever the underlying cause is treated or healed.
LoE:IVb7
GENERAL MEASURES
- Patient counselling.
- Lifestyle adjustment.
MEDICINE TREATMENT
Mild pain:
Non-opioid treatment.
Non-inflammatory or post trauma:
Children
- Paracetamol, oral, 15 mg/kg/dose 6 hourly when required. See: dosing table.
Adults
- Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours).
- Maximum dose: 15 mg/kg/dose.
LoE:IVb8
Pain associated with inflammation:
Adults
- NSAIDs, e.g.:
- Ibuprofen, oral, 400 mg, 8 hourly with or after a meal.
Combine paracetamol and ibuprofen at the above dosages if there is no relief after 2 or 3 doses.
LoE:IVb9
Moderate pain:
If no relief to paracetamol:
ADD
Children
- NSAIDs, e.g.:
- Ibuprofen, oral, 5–10 mg/kg/dose 8 hourly with or after a meal. See: dosing table.
- Discontinue if not effective after 2–3 days.
Refer if there is no response to paracetamol and ibuprofen.
LoE:IVb10
Adults
- NSAIDs, e.g.:
- Ibuprofen, oral, 400 mg, 8 hourly with or after a meal.
- Discontinue if not effective after 2–3 days.
LoE:IVb11
If response to paracetamol and ibuprofen is still inadequate:
ADD
- Tramadol, oral, 50–100 mg, 6 hourly as a starting dose (Doctor prescribed).
- May be increased to a maximum daily dose of 400 mg.
LoE:IVb12
Acute severe pain:
Note:
All children with severe pain should be referred. Ensure patient is comfortable prior to referral.
Children
Morphine solution, oral (Doctor prescribed).
- Starting dose:
- 0–1 month of age: 0.05 mg/kg/dose 6 hourly.
- ≥ 1–11 months of age: 0.1 mg/kg/dose 4-6 hourly.
- ≥ 12 months of age: 0.2–0.4 mg/kg/dose 4-6 hourly.
See dosing table. (Doctor prescribed).
CAUTION
Morphine can cause respiratory depression, monitor carefully.
Adults
- Paracetamol, oral, 500 mg–1 g, 4–6 hourly as required (to a maximum of 4 g in 24 hours).
- Maximum dose: 15 mg/kg/dose.
LoE:IVb13
AND
- Tramadol, oral, 50–100 mg, 6 hourly as a starting dose (Doctor prescribed).
- May be increased to a maximum daily dose of 400 mg.
If no response to paracetamol and tramadol: REPLACE tramadol with morphine:
Morphine solution, oral (Doctor prescribed).
- Starting dose: 5 mg (maximum 0.2 mg/kg) 4 hourly.
- Elderly or frail patients: 2.5–5 mg (maximum 0.1 mg/kg) 4 hourly.
- Adjust morphine doses for patients with renal impairment:
- GFR 10–50 mL/min, 75% of dose,
- GFR <10 mL/min, 50% of dose.
LoE:IVb14
OR
- Morphine, IM, 5–10 mg, 4–6 hourly when required (Doctor prescribed).
LoE:IVb15
OR
- Morphine, IV, to a total maximum dose of 10 mg (Doctor prescribed).
- Dilute 10 mg up to 10 mL with sodium chloride, 0.9%.
- Administer morphine, IV, 3–5 mg as a single dose, then further boluses of 1–2 mg/minute and monitor closely.
- Total maximum dose: 10 mg.
- Repeat after 4 hours if necessary.
- Monitor response to pain and effects on respiration and BP.
LoE:IVb16
|
Patients that require morphine for acute pain of unknown cause or have pain that does not respond with one dose, must be referred for definitive treatment. If no response while awaiting transfer a repeat dose of IV morphine may be given after the initial bolus dose of 3-5 mg. |
Precautions and special comments on the use of morphine:
- Morphine may cause respiratory depression. This can be reversed with naloxone. See: Exposure to Poisonous Substances
- Do not administer morphine in:
- Severe head injury
- Acute asthma
- Uncontrolled hypothyroidism
- Morphine can be used for acute abdominal pain without leading to surgical misdiagnosis.
- Use morphine with extreme care in the following:
- Recent or concurrent alcohol intake or other CNS depressant.
- Advanced chronic obstructive pulmonary disease, or other respiratory disease with imminent respiratory failure
- Hypovolaemia or shock
- Advanced liver disease
- The elderly
- Use morphine with extreme care in these circumstances, and monitor response to pain and effects on respiration and BP.
|
If morphine has been administered, document the time and dose of administration on the referral letter as this may alter some of the clinical features of acute abdomen or head injury. |
REFERRAL
- All children with acute severe pain.
- No response to oral pain control and unable to initiate opioid therapy.
- Uncertain diagnosis.
- Management of serious underlying conditions.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_07 November 2024
Chapter 20: Pain_20.2 Acute Pain