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Background and aims Previous studies have described the phenomenon of oligo-analgesia in Emergency Department patients with traumatic injuries, despite the high prevalence of pain among these patients. Besides aspects related to health care staff, patient related factors might also play a role in suboptimal pain treatment, however evidence is scarce. Therefore, the objective of the current study was to evaluate patient related factors in adult patients refusing offered analgesics during an Emergency Department presentation with extremity injuries. Methods This was a case control study in the Emergency Department of a level 1 Trauma Centre. Cases were defined as adult patients with an extremity injury who declined analgesia, when offered. They were matched to controls from the same population, who accepted analgesics, in a 1:2 ratio using gender as matching variable. Primary outcome was difference in NRS pain score. Secondary outcomes were the relationship between categorical severity of pain scores and refusal of analgesics, exploration of independent predictors of analgesia refusal utilizing multivariate logistic regression and the evaluation of eight beliefs among patients who refuse analgesics. Results Between August 1st and 31st 2016, a total of 253 patients were eligible for inclusion of whom 55 declined analgesic treatment. They were included as cases and matched to 110 controls. Difference in median NRS pain score was significant between the groups: 5.0 (IQR 3.0-8.0) vs. 8.0 (IQR 6.0-9.0), respectively (p < 0.01). Nearly 20% of patients with severe pain declined analgesics, compared to 41% with moderate and 69% with mild pain (p < 0.01). The NRS pain score was the only independent predictor of refusal of analgesic treatment with a mean Odds Ratio of 0.67 (95%-CI 0.54-0.83). Most common patients' beliefs were that pain medication should be used in extreme pain only, fear of decreasing the doctor's ability to judge the injury and fear of addiction to analgesics. Conclusions Pain severity is the single independent predictor of refusal of analgesia, however the following patient beliefs are important as well: pain medication should be used in extreme pain only; fear of decreasing the doctor's ability to judge the injury and the fear of becoming addicted to pain medication. Implications In case patients refuse offered analgesics, the health care provider should actively address patient beliefs that might exist and lead to suboptimal pain treatment.

Objectives: Pain treatment in acute musculoskeletal injuries usually consists of paracetamol, non-steroidal antiinflammatory drugs (NSAIDs) or opioids. It would be beneficial to determine whether paracetamol is as effective as other analgesics. The objective of this study was to evaluate available evidence regarding efficacy of paracetamol in these patients., Methods: Embase, MEDLINE, Cochrane and relevant trial registers were searched from inception to 14 February 2018 by two independent reviewers to detect all randomised studies with adult patients with acute minor musculoskeletal injuries treated with paracetamol as compared with other analgesics. There were no language or date restrictions. Two independent reviewers evaluated risk of bias and quality of evidence. Primary outcome was decrease in pain scores during the first 24 hours, and secondary outcomes included pain decrease beyond 24 hours, need for additional analgesia and occurrence of adverse events., Results: Seven trials were included, evaluating 2100 patients who were treated with paracetamol or NSAIDs or the combination of both as comparisons, of which only four studies addressed the primary outcome. No studies were found comparing paracetamol with opioids. There were no differences in analgesic effectiveness within and beyond 24 hours, nor in need for additional analgesia and occurrence of adverse events. Overall, quality of evidence was low. Because of methodological inconsistencies, a meta-analysis was not possible., Conclusions: Based on available evidence, paracetamol is as effective as NSAIDs or the combination of both in treating pain in adult patients with minor musculoskeletal injuries in the acute setting. The quality of evidence is low., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Objective: We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma., Methods: The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547 adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive days and need for additional analgesia., Results: One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin., Conclusion: Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Topical application of lidocaine in wounds has been studied in combination with vasoconstrictive additives, but the effect without these additives is unknown. The objective was to examine use of lidocaine-soaked gauzes without vasoconstrictive agents, in traumatic wounds in adult patients, applied in triage., Methods: A prospective pilot study was performed during 6 weeks in the Emergency Department of a level 1 trauma center. Wounds of consecutive adult patients were treated with a nursing protocol, consisting of lidocaine hydrochloride administration directly into the wound and leaving a lidocaine-soaked gauze, until wound treatment. Primary outcome was need for infiltration anesthesia. Secondary outcomes were Numerical Rating Scale (NRS) pain scores, adverse events and patient and physician satisfaction., Results: Forty patients with a traumatic wound were included, 85% male with a wound on the arm. Thirty-seven patients needed a painful procedure as wound treatment. When suturing was necessary, 77% required additional infiltration anesthesia. Mean NRS pain scores decreased from 3.3 to 2.2 after application of the lidocaine gauze. No adverse events were recorded. Of the patients, 60% were satisfied with use of the lidocaine gauzes, compared to 40% of physicians., Conclusion: Lidocaine hydrochloride (2%) gauzes without vasoconstrictive additives cannot replace infiltration anesthesia in traumatic wounds., (Copyright © 2016 Elsevier Ltd. All rights reserved.)