Goal: Irrigating, debriding, repairing, and bandaging wounds can be painful for the patient. Analgesia is often necessary to facilitate wound care and sedation may be required for more severe wounds.

- Best: Regional nerve block (for extremity wounds, ONLY if fully trained and equipped); and/or ketamine drip augmented with versed IV push as needed.
- Better: Local anesthetic and/or ketamine drip augmented with versed IV push as needed.
- Minimum: Local anesthetic and/or any pain medication.

1. 1% or 2% lidocaine (with or without epinephrine)
2. Oral (i.e., by mouth [PO]) acetaminophen and meloxicam
3. PO acetaminophen/oxycodone (e.g., Percocet; Endo Pharmaceuticals, http://www.endo.com)
4. Oral transmucosal fentanyl
5. IV/IM ketamine
6. IV morphine, hydromorphone, or fentanyl

Local anesthetic notes:

- For smaller wounds that require painful interventions, direct injection of local anesthetic into the wound margins with 1% or 2% lidocaine can provide enough analgesic effect for the patient’s comfort.
- The maximum dose of lidocaine WITHOUT epinephrine is 3mg/kg (1% lidocaine has 10mg/mL and 2% lidocaine has 20mg/mL).
- The maximum dose of lidocaine WITH epinephrine is 7mg/kg (1% lidocaine has 10mg/mL and 2% lidocaine has 20mg/mL).
- Epinephrine injected with lidocaine has several properties that are advantageous: reduces bleeding, increases the duration of the local anesthetic effect by at least 50% depending on the site, and raises the maximum dose.
- Injection of epinephrine-containing anesthetics should be used with caution in the tip of the nose, ear, penis, fingers and toes, because of possible risk of ischemia.
- Buffering lidocaine with sodium bicarbonate using a 9:1 ratio (9mL lidocaine with 1mL bicarbonate), keeping the lidocaine at room temperature, and using smaller gauge needles can lessen the burning sensation associated with injection.
- Sodium bicarbonate buffers the acidity of local anesthetics, allowing for a more rapid analgesic onset.
- If properly trained and equipped with an ultrasound machine, the provider can perform ultrasound-guided regional blocks for those wounds in which local anesthesia will not manage the pain effectively during wound care. See Analgesia and Sedation CPG for PFC.
- For wounds that require the patient to be on a surgical plane, see Analgesia and Sedation CPG for PFC.

See the Analgesia and Sedation CPG for PFC for a more comprehensive summary.