St Emlyn’s Lesson Plans

Analgesia in the Emergency Department

Discuss prompt pain relief, prescribing risks and how to check whether treatment has helped.

New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session

For learners

Before: Allow about 15 minutes in total.

When we meet: We will compare prescribing decisions for similar injuries and discuss a severely injured patient who becomes drowsier after treatment.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Local pain-assessment tool, blank medicines and observation charts, and current formulary. No medicines, needles or completed sample prescription needed.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 15 minutes in total.

Core preparation

RCEM: Management of Acute Pain in Adults · About 12 minutes

Read the RCEM assessment, timely-treatment and reassessment sections. Focus on previous doses, patient-specific risks and how response should be recorded.

https://rcem.ac.uk/wp-content/uploads/2024/10/Management_of_Acute_Pain_in_Adults_2024_v1.pdf

Think about (allow 3 minutes): What do you need to know about medicines already taken before prescribing more analgesia?

Picture the scene

A patient with an injured ankle is still in pain after taking tablets at home. The nurse asks what else can safely be given.

By the end of the session

Assess pain and agree a functional treatment goal.
Choose a route and analgesic plan after checking relevant risks and prior doses.
Describe when and how to reassess benefit and adverse effects.

After the session

Review one analgesia prescription on your next shift: did anyone document its effect?
Ask a patient what functional improvement matters to them.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 15 minutes in total.

Before learners arrive

Bring the current adult analgesia formulary and monitoring policy.
Confirm where analgesics, immobilisation equipment and rescue equipment are kept.
Identify staff competent to supervise regional analgesia.
Use the first case to list the missing medicines-history questions on a blank chart; no unseen sample history is required.

Equipment: Local pain-assessment tool, blank medicines and observation charts, and current formulary. No medicines, needles or completed sample prescription needed.

Setup: Pairs review the medicines history in the first case and agree a treatment goal. For the second case, one person proposes a plan and the other checks monitoring and reassessment before they swap roles.

If the preparation has not been completed

Replace goal setting and the prescribing check (12 minutes). Use the linked RCEM assessment and reassessment sections for eight minutes, then use the first case for four minutes to identify the medicines history still needed. No completed medicines chart is required. Continue with the cases at minute 12. For the 30-minute version, use the first eight minutes for a four-minute shared read and four-minute risk check, replacing goal setting and risk checks.

Suggested session plan

0–5 min — Define useful pain relief. Ask what the patient wants to be able to do.
5–12 min — Check before prescribing. Pairs list information needed about medicines already taken.
12–34 min — Discuss contrasting cases. Keep returning to route, contraindications and reassessment.
34–40 min — Write a monitored plan. Each group states the next review time and adverse effects to look for.
40–45 min — Choose a follow-up action. Identify one avoidable delay in local analgesia delivery.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

The same injury, different prescribing decision

A 45-year-old with a painful knee after football has taken “some ibuprofen”.

Add this information as the discussion develops:

Now consider the same injury in an older person taking an anticoagulant with reduced kidney function.

Ask the group:

What do you need to ask before prescribing?
Which non-drug measures help now?
What would successful treatment look like?

Discussion notes

Points to draw out:

Establish exact preparations, dose and timing, allergies, weight where relevant, renal/hepatic disease and interacting medicines.
Protect and support the injury, explain the plan and offer appropriate analgesia without waiting for imaging.
NSAID suitability changes with GI, renal, cardiovascular and bleeding risks; verify the current formulary rather than declaring one drug universally safest.

Common misconceptions:

Stacking combination products containing the same drug.
Assuming a low numerical score means no treatment is wanted.

For a more experienced group: Discuss how to assess pain when communication or cognition is impaired.

Severe injury needs a monitored plan

A patient has a painful deformed thigh after a motorcycle fall. They are frightened and cannot tolerate movement.

Add this information as the discussion develops:

After treatment they become drowsier while pain remains severe.

Ask the group:

What needs to happen alongside analgesia?
How do you choose route and monitoring?
What would make you stop and reassess?

Discussion notes

Points to draw out:

Assess for major trauma and haemorrhage; provide immobilisation and timely analgesia with senior support.
Titrate treatment to effect under local protocols, accounting for physiology and risk; arrange monitoring and reassessment.
Drowsiness is a reason to reassess airway, ventilation, perfusion and drug effect, not simply to give another dose.
Regional analgesia requires a trained clinician, appropriate monitoring, dose checks and a plan for local-anaesthetic toxicity.

Common misconceptions:

Using a fixed opioid dose as a minimum regardless of frailty or instability.
Letting analgesia distract from deterioration.

For a more experienced group: Compare a regional technique with systemic analgesia for a suitable patient, including consent and supervision.

Important clinical points

Verify cumulative doses, combination products and local formulary limits before prescribing.
Monitor consciousness, breathing and circulation after parenteral opioids; severe pain does not protect against respiratory depression.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

How would kidney disease change your plan?
When is an intravenous route justified?
What should happen if pain and sedation both worsen?

Key teaching points:

Offer timely pain relief after checking previous doses and relevant risks.
Agree when benefit and adverse effects will be reassessed.
Use explanation, positioning and support for the injury alongside medicines.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Choice of drug and route depends on patient risk, local availability and competence; this discussion is not a universal dosing chart.

If the discussion drifts

What will we reassess to know the treatment helped safely?

For a more experienced group

Explore severe pain in frailty, renal impairment or opioid tolerance without assuming drug-seeking behaviour.

A 30-minute version

30 minutes: goal setting 3; risk checks 5; two cases 17; consolidation and reflection 5. Omit the equipment walkthrough.

Evidence and guidance

RCEM: Management of Acute Pain in Adults — September 2024 best practice guideline; assessment, treatment and reassessment.https://rcem.ac.uk/wp-content/uploads/2024/10/Management_of_Acute_Pain_in_Adults_2024_v1.pdf