From the Guidelines
In the emergency department, treatment for reflex sympathetic dystrophy (RSD) pain, also known as complex regional pain syndrome (CRPS), should prioritize non-opioid analgesic therapies as the initial treatment, with intravenous NSAIDs like ketorolac 15-30mg IV and consideration of ketamine at sub-anesthetic doses (0.1-0.3 mg/kg IV) for neuropathic pain management, as recommended by the most recent guidelines 1.
Treatment Approach
When managing RSD pain in the emergency department, the focus should be on rapid pain control and breaking the pain cycle. The treatment approach should include:
- Intravenous NSAIDs like ketorolac 15-30mg IV (if no contraindications) for immediate relief
- Consideration of ketamine at sub-anesthetic doses (0.1-0.3 mg/kg IV) which works well for neuropathic pain by blocking NMDA receptors
- Regional nerve blocks performed by an anesthesiologist can provide significant relief; options include stellate ganglion blocks for upper extremity pain or lumbar sympathetic blocks for lower extremity involvement
- Oral gabapentinoids (gabapentin 300mg or pregabalin 75mg) can be initiated in the ED and continued as outpatient therapy
Physical Measures and Follow-up
Physical measures like elevation of the affected limb, application of cold packs, and gentle range-of-motion exercises should complement pharmacological treatment. Before discharge, ensure adequate oral pain control, arrange prompt follow-up with pain management specialists, and educate the patient about the importance of continuing physical therapy and medication compliance, as early aggressive treatment improves long-term outcomes for this challenging pain syndrome, as noted in the management of chronic pain 1.
Opioid Use
According to the 2020 clinical policy on opioids in adult patients presenting to the emergency department 1, opioid medications should be prescribed at the lowest effective dose of a short-acting opioid for the shortest time indicated, preferring non-opioid analgesic therapies as the initial treatment of acute pain in patients discharged from the ED.
From the Research
Treatment Approaches for Reflex Sympathetic Dystrophy Pain
- The treatment of reflex sympathetic dystrophy (RSD) is not clearly delineated, and there are few controlled studies regarding rehabilitation as medicine 2.
- A treatment approach for RSD may include analgesics, nonsteroidal anti-inflammatory drugs, and intra-articular steroids 2.
- Calcitonin is used as the primary treatment at early stages of the disease, especially in Europe 2.
- Local intravenous injections may be used in case of failure of previous treatments 2.
- Physical therapy and rehabilitation are also needed to decrease pain and improve stiffness 2.
Pharmacological Interventions
- Methylprednisolone may be used as a dose pack for 1 to 2 weeks, followed by a nonsteroidal anti-inflammatory such as indomethacin 3.
- Amitriptyline may be helpful for sleep and depression, and also has a beneficial effect on blood flow 3.
- Calcium channel blockers (nifedipine) may help improve peripheral circulation by its effect on vascular smooth muscle 3.
Sympathetic Blockade
- Stellate ganglion blocks may be used as an alternative modality for pain management, especially for patients with established chronic pain 3.
- Patients may require at least 2 blocks before deciding whether or not blocks are helpful, and may benefit from 3 blocks a week, every other day for 3 weeks 3.
- Occupational or physical therapy immediately following the block may enhance the benefit of the blocks 3.
Surgical Interventions
- Surgical sympathectomy may be helpful but only in patients who have responded to sympathetic blockade 3.