Contusions Medication

The physician needs to make every effort to relieve pain as completely and expeditiously as possible. Distinguishing the intensity of the pain can be difficult, because it tends to be subjective; therefore, treatment and therapy should be individualized.

Objective parameters, such as tachycardia, are unreliable. Usually, minor trauma to the muscles is self-limited. An enormous selection of analgesics is available for use by the physician, but pharmacologic agents tend to fall into 2 general categories: nonnarcotic and narcotic analgesics. The physician also must consider the best route of delivery of the drug.

Corticosteroids should not be used; they are catabolic, and they inhibit the healing process. These steroids promote overall negative nitrogen balance and loss of muscle. However, these agents continue to be used clinically to treat muscle contusion injuries and are injected into the site of injury to relieve the pain and to expedite a player's return to active status. This inhibition of the inflammatory response may have a sparing effect on the local muscle tissue and, perhaps, on the athlete as a whole in the short term; however, corticosteroids seem to cause an unwanted atrophy of both injured and uninjured muscles.^{[19, 20, 21]}

Anabolic steroids may be proven useful in the treatment of contusion injuries because of the effects they have on nitrogen and protein balance and on stimulation of cell synthesis; however, research currently is limited.^[19] Many sporting governing bodies also control the use of anabolic steroids in their athletes, making the use of these agents controversial.

Class Summary

Pain accompanying minor acute soft-tissue injuries may be relieved by a short course of nonnarcotic analgesics with acetaminophen.

Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)

Ordinarily, the most commonly ingested pain reliever. Also marketed in combination with other drugs to provide analgesia. Advantages include availability, cost, and relatively high safety profile. The onset of relief is usually within 20-30 min. Extended release preparations do not appear to offer major benefits (other than dosing convenience) and may increase the incidence of toxicity. For children, acetaminophen is available as drops (80 mg/0.8 mL), elixirs (160 mg/5 mL), tablets (80 mg, 160 mg, 325 mg), and suppositories (125 mg, 325 mg).

Class Summary

Controversial data exist on NSAIDs. By suppressing the initial inflammatory reaction, the NSAID permits improved performance in early time periods but appears to suppress the stimulus that may be needed for cellular remodeling in longer time periods. NSAIDs also may increase the amount of bleeding within the tissue. Currently, there is a lack of compelling evidence for either argument.

Although acetaminophen is typically listed with NSAIDs, this agent lacks anti-inflammatory properties and is used for its antipyretic and analgesic effects.

A number of NSAIDs are available for use. NSAIDs share a common mechanism of action, inhibiting the production of pain-mediating prostaglandins. Generally, NSAIDs provide a comparable degree of pain and inflammatory relief, but they differ in dosing schedule.

The 5 categories of marketed NSAIDs are acetic acid derivatives, fenamates, oxicams, propionic acid derivatives, and related compounds. Numerous NSAIDs are obtainable over the counter (OTC). Choosing an NSAID to prescribe can be difficult because few data exist that compare these agents, and individual responses are inconsistent. With a lack of evidence that one NSAID proves to be clearly superior, base prescribing decisions on personal experience, safety profiles, cost, and convenience.

Indomethacin (Indocin)

Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.

Ketorolac (Toradol)

Has become the choice of parenteral pain medications dispensed in the ED. Frequently overlooked is the fact that this medication is an NSAID, carrying all its attendant risks, and it is almost 20 times the cost of morphine (and 140 times the cost of ibuprofen). Few data supporting its superiority over other analgesics exist.

Ibuprofen (Motrin, Advil, Nuprin)

This prevalently used NSAID, also available OTC, is a derivative of the propionic class of NSAIDs and is considered the safest of the NSAIDs. Available as tablets of 200 mg, 400 mg, 600 mg, and 800 mg. Pediatric dosage forms are available as both a tablet and oral suspension (20 mg/mL). Advise taking ibuprofen with food or milk, if possible. Prescribe with caution in children with flulike illnesses.

Class Summary

Patients complaining of inadequate pain relief from NSAIDs may benefit from short-term supplementation with an opioid compound. A wide array of products is available.

Orally (PO), hydrocodone (eg, Lortab, Lorcet, Vicodin, Anexsia), a schedule III narcotic, and oxycodone (eg, Roxicet, Percodan, Tylox), a schedule II substance, usually provide additional pain relief. Codeine-containing products (schedule III drugs) are not as reliable for alleviating pain. Although the relative potency for oxycodone and hydrocodone is approximately 0.33 (compared with parenteral morphine), that for oral codeine is 0.05. Mixed agonist-antagonist oral agents, such as butorphanol, nalbuphine, and pentazocine, offer no real advantages to opioid agents; yet, they cause a higher incidence of adverse effects. Common side effects include constipation, nausea, respiratory depression, sedation, and urinary retention.

Generally, the approved dosage of hydrocodone is 5-10 mg, combined with 500-750 mg of acetaminophen and taken PO every 6 hours as needed (q6h prn). Oxycodone analgesic preparations typically combine 2.5-5 mg of oxycodone with 325 mg of acetaminophen. They are dosed as 1-2 tablets PO q4h prn for moderate to severe pain. Acetaminophen with codeine (Tylenol #3) contains 30 mg of codeine with 325 mg of acetaminophen. Usually, 1-2 pills q4h prn is recommended.

Elixirs containing hydrocodone (Hycodan) are convenient for children older than 6 years who have moderate to severe pain and who are unable to swallow pills. One teaspoon (5 mL) of Hycodan contains 5 mg of hydrocodone; the dose usually is 1.25-2.5 mg q4h, depending on the child's size and the severity of pain. The elixir of Tylenol with codeine for children contains 120 mg of acetaminophen and 12 mg/5 mL of codeine in an alcohol base (7%).

Generally, orally administered drugs impart a slower onset of action. For patients in severe pain or for those patients who must take nothing by mouth (NPO), parenteral agents may be necessary. Although the intramuscular (IM) route may be more convenient for the staff, the intravenous (IV) route offers a number of advantages. Narcotics given IV provide a rapid and predictable onset of action and are easier to titrate. Morphine and meperidine are the most commonly used parenteral narcotic agents.

Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab, Anexsia)

A drug combination indicated for the relief of moderate to severe pain.

Oxycodone and acetaminophen (Percocet, Tylox, Roxicet)

Drug combination indicated for the relief of moderate to severe pain.

Acetaminophen and codeine (Tylenol #3)

A drug combination indicated for the treatment of mild to moderate pain.