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Pain control in ED 2010

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  • Higher rate of GI bleeding than ibuprofen
  • VIGOR trial demonstrated increased rate of MI in patients taking Vioxx, and APPROVe study with inceased incidence of thromboembolic events Prostaglandin mediated negative endothelial lining effect Platelet effect may be negative
  • 3-4 mg/kg IM with atropine 0.01 mg/kg in same syringe (or 1-2 mg/kg IV)
  • Same dosing for peds

Pain control in ED 2010 Presentation Transcript

  • 1. Pain Management in the ED Elise O. Lovell, MD
  • 2. Pitfalls in Pain Management
    • Oligoanalgesia (too little)
    • Withholding analgesics until definitive diagnosis is made (too late)
    • Inappropriate route of administration
    • Inappropriate dosing schedule
    • Waiting for the patient to ask
    • Inappropriate discharge analgesic
  • 3. Some specific analgesics
    • Ketorolac (Toradol)
    • Cox-2 Inhibitors
    • Tramadol (Ultram)
    • Propoxyphene (Darvon)
    • Codeine/Hydrocodone/Oxycodone
    • Meperidine (Demerol)
    • Fentanyl (Sublimaze)
    • Morphine
    • Hydromorphone (Dilaudid)
  • 4. Case 1
    • 28 yo male, MVC, isolated right leg pain.
    • PMH: neg, no allergies
    • VS: 140/80, 90, 18
  • 5. Case 1
  • 6. Case 2
    • 30 yo female, left flank pain, hematuria, vomiting
    • PMH: neg, no allergies
  • 7. Case 2
  • 8. Case 3
    • 19 yo male, RLQ pain, fever, anorexia
    • PMH: neg, no allergies
    • Surgeon calls and says: Don’t give him any pain medication, it will mess up my exam !!
  • 9. Case 4
    • 50 yo female, distal radius fracture, no reduction needed, in splint, ready for discharge.
    • PMH: negative, no allergy
  • 10. Case 5
  • 11. Ketorolac (Toradol)
    • Cyclooxygenase inhibition
    • Same GI side effects as all NSAIDS
    • Similar efficacy to Ibuprofen
    • Effective in renal and biliary colic
    • Obstructed kidney uses vasodilation to preserve perfusion (prostaglandin mediated effect), ketorolac -> ATN
  • 12. COX-2 Inhibitors
    • Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Bextra)
    • Efficacy similar to other NSAIDS
    • Improved GI profile (maybe)
    • Increased risk of MI and CVA
    • All NSAIDS with Renal, BP,GI effects, edema
  • 13. COX-2 Inhibitors
    • Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Bextra)
    • Efficacy similar to other NSAIDS
    • Improved GI profile (maybe)
    • Increased risk of MI and CVA
  • 14. Codeine/Hydrocodone/Oxycodone
    • Multiple strengths
    • Often mixed with ASA/tylenol
  • 15.  
  • 16. Tramadol (Ultram)
    • Binds to mu opioid receptors, also inhibits norepi/serotonin reuptake
    • Similar analgesic potency to codeine
    • Seizure risk
    • Nausea, dizziness, sedation, constipation
    • Serotonin syndrome with SSRI
  • 17. Propoxyphene (Darvon)
    • Synthetic narcotic
    • In OD, expect seizures, also can cause cardiac toxicity (blocks), requires high doses of narcan to reverse
  • 18. Fentanyl (Sublimaze)
    • Stable hemodynamic profile
    • Minimal histamine release
    • High dose rapid push --> “rigid chest syndrome”. Treat with naloxone and muscle relaxants
    • Large dose -->possible apnea
    • Small doses frequently (1-2 mic/kg, duration 30-60 minutes)
    • Also transdermal patch, lozenge,
    • inhaled
  • 19.  
  • 20. Morphine
    • Analgesic dose 0.1 mg/kg
    • Dosing ceiling from side effects, not from arbitrary number of mg
  • 21.  
  • 22. Hydromorphone (Dilaudid)
    • High potency (1 mg equals 7 mg morphine)
  • 23.  
  • 24. Meperidine (Demerol)
    • Not available (except for shivering)
    • Risk of seizures from Normeperidine in high dose (sickle cell anemia) and in renal failure
    • Serotonin syndrome with MAOI
  • 25. Procedural Sedation
    • Fentanyl/Versed
    • Ketamine
    • Methohexital (Brevital)
    • Propofol (Diprivan)
    • Etomidate
  • 26.  
  • 27. Ketamine
    • Derivative of PCP
    • Use in kids (age 1-10 years) for short painful procedures
    • Onset 5 minutes, lasts approx. 30 minutes
    • Dissociative state-eyes open, no one home
    • Midazolam helps nausea, likely does NOT decrease emergence phenomena
    • Atropine no longer recommended
  • 28. Ketamine, continued
    • Normal or increased muscle tone
    • Preserved airway reflexes
    • Analgesia, amnesia
    • Stable or increased BP and Pulse
    • Bronchodilator
  • 29. Ketamine, the downside
    • Increases ICP and IOP
    • Apnea in children < 1 year
    • Increased secretions ->laryngospasm (bag through it)
    • Emergence phenomena (older kids)
    • Complete recovery -> 1 hour (concern of head positioning)
    • Emesis
  • 30. Propofol (Diprivan)
    • Sedative hypnotic-NOT analgesic
    • Onset 40 seconds, off in 5-10 minutes
    • Side effects: Hypotension, Apnea, Infection
    • Decreases ICP, anti-emetic, anti-epileptic
    • Decreased side effects with infusion rather than bolus
    • Different dosing for induction vs. procedural sedation vs. maintenance
  • 31. Propofol (Diprivan) Dosing
    • May add low dose fentanyl (1 mic/kg IV) as analgesic, and use lower propofol dose
    • Pediatrics- use 1 mg/kg IV
    • “ propofol syndrome” in kids seen in PICU-longer duration sedation (acidosis, hypotension, organ failure)
  • 32. Let’s mix them together: “Ketofol”
    • 1:1 mixture in same syringe
    • Usual dose required approximately 1.0 mg/kg
    • Best of both worlds (less hypotension, less resp. sedation, less vomiting, less emergence)
  • 33.  
  • 34. Methohexital (Brevital)
    • Not currently available
    • Ultra short acting barbiturate
    • 1-1.5 mg/kg IV push
    • Not an analgesic
    • Can cause apnea, decreased BP, also possible laryngospasm, myoclonus, bronchospasm, N/V
  • 35. Etomidate
    • Sedative hypnotic, NOT analgesic
    • Induction dose 0.3 mg/kg IV push, use 0.15 mg/kg for procedural sedation
    • Onset within one minute, off in about 10 minutes
    • Decreases ICP and IOP
    • Stable CV effects
    • Can cause myoclonus (not seizures), vomiting, respiratory depression
    • Adrenal suppression-consider alternative in sepsis
  • 36. Take home points
    • Dose analgesics to effectiveness, not an arbitrary number of mg
    • Dose early, dose often
    • Be proactive about offering analgesics
    • Remember the potency of Dilaudid
    • Ketorolac is expensive Ibuprofen
    • Etomidate and Propofol are NOT Analgesics
  • 37.  
  • 38.  
  • 39. Propofol (Diprivan) dosing
    • Procedural sedation: usually slow push 1-1.5 mg/kg with repeated dosing of 0.5 mg/kg, duration 8-10 minutes
    • Induction: 2-2.5 mg/kg, usually give 40 mg every 10 seconds (elderly 20 mg every 10 seconds)
    • ICU sedation: 5 mic/kg/min (0.3 mg/kg/hr) increase by 10 mic/kg/min (0.6 mg/kg/hr) every 5-10 minutes