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

    1. 1. Pain Management in the ED Elise O. Lovell, MD
    2. 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. 3. Some specific analgesics Ketorolac (Toradol) Cox-2 Inhibitors Tramadol (Ultram) Propoxyphene (Darvon) Codeine/Hydrocodone/Oxycodone Meperidine (Demerol) Fentanyl (Sublimaze) Morphine Hydromorphone (Dilaudid)
    4. 4. Case 1 28 yo male, MVC, isolated right leg pain. PMH: neg, no allergies VS: 140/80, 90, 18
    5. 5. Case 1
    6. 6. Case 2 30 yo female, left flank pain, hematuria, vomiting PMH: neg, no allergies
    7. 7. Case 2
    8. 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. 9. Case 4 50 yo female, distal radius fracture, no reduction needed, in splint, ready for discharge. PMH: negative, no allergy
    10. 10. Case 5
    11. 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. 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. 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. 14. Codeine/Hydrocodone/Oxycodone Multiple strengths Often mixed with ASA/tylenol
    15. 15. 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
    16. 16. Propoxyphene (Darvon) Synthetic narcotic In OD, expect seizures, also can cause cardiac toxicity (blocks), requires high doses of narcan to reverse
    17. 17. 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
    18. 18. Morphine Analgesic dose 0.1 mg/kg Dosing ceiling from side effects, not from arbitrary number of mg
    19. 19. Hydromorphone (Dilaudid) High potency (1 mg equals 7 mg morphine)
    20. 20. 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
    21. 21. Procedural Sedation Fentanyl/Versed Ketamine Methohexital (Brevital) Propofol (Diprivan) Etomidate
    22. 22. 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
    23. 23. Ketamine, continued Normal or increased muscle tone Preserved airway reflexes Analgesia, amnesia Stable or increased BP and Pulse Bronchodilator
    24. 24. 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
    25. 25. 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
    26. 26. 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)
    27. 27. 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)
    28. 28. 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
    29. 29. 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
    30. 30. 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
    31. 31. 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

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