Acute pain mx pgy1&2 2013

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Acute pain mx pgy1&2 2013

  1. 1. Chris Cresswell Emergency Physician Whanganui New Zealand 2013 Acute Pain Management PGY 1+2
  2. 2. Analgesia Do the basics well Reassurance
  3. 3. Splintage Immobilise broken bits early Sling Cardboard splint
  4. 4. Polypharmacy is Cool!
  5. 5. Paracetamol Loading dose: 2g PO or 1g IV or 20mg/kgPO or 15mg/kg IV Maintenance dose: PO 15mg/kg q4h or max 8g/day for adults NASIDs eg Ibuprofen 10mg/kg tds Highly effective Be careful in the elderly, CCF, renal impairment Codeine – effective when used with paracetamol– easier for
  6. 6. Consider paracetamol toxicity in someone who has had difficult to control pain in the community - typically toothache > 20 tab in 24 hours or > 24 tab in 48 hours -> N-acetylcysteine and ask questions later.
  7. 7. Can’t take pain relief orally? Paracetamol IV (usually only 1g) or PR Parenteral NSAID eg Diclofenac IV (75mg in 100ml N Saline) Almost never use IM analgesia in ED Slow Painful
  8. 8. 1µg/kg IV q3min, 3µg/kg IN prn q5min Use half the dose in elderly or drugged (eg ethanol or morphine) IV dose can be repeated in a few minutes PRN Doesn’t make people puke, itch, hypotensive or as sedated as as morphine Shorter acting than morphine. Use morphine once patient analgesed if long acting analgesia needed. Fentanyl
  9. 9. Nitrous oxide 50:50 nitrous oxide : oxygen “Entonox” Moderate analgesic Very safe Theoretical risks of diffusing into and expanding closed spaces eg pneumothorax, bowel obstruction, hernias Requires patient to suck to activate valve -> children under 5 usually unable to use Use it for catheters or IV access in needlephobes
  10. 10. 70% Nitrous Oxide 70% Nitrous oxide : 30% oxygen Strong analgesic and sedative Can often suture with this Need an oxygen wash-out to prevent hypoxia
  11. 11. Nerve blocks Do a neurovascular exam first! Use a long acting local anaesthetic eg bupivocaine, Lignocaine if you want sensation early, eg lips Great for hips and femurs – femoral nerve or triple block. Maximum doses?
  12. 12. Local anaesthetic maximum doses Bupivacaine max dose 2mg/kg Repeated doses up to 400mg/day can be used1 Lignocaine max 4.5mg/kg without adrenaline 7mg/kg with adrenaline Adrenaline can be put into appendages. 1: http://www.medsafe.govt.nz/profs/datasheet/m/MarcainAndadrenalineinj.pdf
  13. 13. Signs of local anaesthetic toxicity?
  14. 14. Signs of local anaesthetic toxicity. Perioral tingling Visual disturbance Seizure Coma VT Antidote?
  15. 15. Antidote for LA toxicity Fat emulsion eg Intralipid 1ml/kg prn q3minutes then infusion
  16. 16. Fascia Iliaca Block AKA triple block Triple block (femoral, lateral cutaneous nerve of thigh, obtruator) by the double pop fascial puncture technique is fantastic, super safe analgesia for # NOF and # femur 1 fascia lata, 2 fascia iliaca, 3 N. femoralis, 4 N. cutaneus femoris lateralis, 5 V. and A. femoralis, 6 M. pectinale, 7 M. psoas
  17. 17. Other blocks There are lots other great places you can stick local anaesthetic Femoral nerve block Digital nerves: Go into the dorsum of the webspace ~ 2ml of local on each side of the finger # ribs 5 ml of local over the # site Median, radial and ulnar nerve blocks at the wrist. 5ml per nerve Haematoma blocks for # wrist 10ml into the # Dental anaesthesia Inject 3ml of long acting local injected through the buccal sulcus into soft tissue adjacent to the gum at the effected tooth Rarely a Inferior alveolar nerve block will be needed for a lower molar.
  18. 18. Tramadol Tramadol is for people who say it works well for or patients you don’t like Old adage: Works for 1/3 Useless for another 1/3 Makes 1/3 vomit or spin out Crappy analagesic eg Oxford league table of analgesics in acute pain Very good for people who you think are drug seeking. Tramadol is not “liked” by IVDU but they are often tolerant to it’s side effects and do get an analgesic effect.
  19. 19. Benzodiazepines No analgesic effect, no muscle relaxant effect at sub-anaesthetic doses But may help patients tolerate pain But usually better to use an analgesic than has sedative properties eg opioid, clonidine Considered a harmful treatment for acute low back pain (as are opioids) New Zealand acute low back pain guide, incorporating the guide to assessing psychosocial yellow flags in acute low back pain http://www.acc.co.nz/
  20. 20. Smooth muscle relaxants eg buscopan Little evidence of effect Emergency department management of undifferentiated abdominal pain with hyoscine butylbromide and paracetamol: a randomised control trial. http://www.ncbi.nlm.nih.gov/pubmed/22307926 Butylscopolammonium bromide does not provide additional analgesia when combined with morphine and ketorolac for acute renal colic. http://www.ncbi.nlm.nih.gov/pubmed/22487663 Is there a role for antimuscarinics in renal colic? A randomized controlled trial. http://www.ncbi.nlm.nih.gov/pubmed/16006900 Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the symptomatic treatment of acute biliary colic. http://www.ncbi.nlm.nih.gov/pubmed/15230794 Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Buscopan (hyoscine butylbromide) in abdominal colic. http://www.ncbi.nlm.nih.gov/pubmed/12748151
  21. 21. Skeletal Muscle Relaxants eg orphendarine Some evidence of benefit But generally we prefer analgesics over muscle relaxants Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. http://www.ncbi.nlm.nih.gov/pubmed/17909211
  22. 22. Ketamine - analgesia Low dose ketamine is an excellent analgesic But some patients spin out – unpredictable which ones Eg 0.1mg/kg prn q 5min IV. Advise patients that it is “trippy”. Sell it to them that it will be pleasant. Maximum dose of ketamine for unsupervised RMO probably 30mg If someone is nervous give eg 1mg of midazolam IV before hand Talk them through it as it is “coming on”
  23. 23. Ketamine - analgesia Cautions Elderly Start with 5mg Psych history, IHD, marked hypertension Get senior advice
  24. 24. Other agents Seldom used outside of theatre Clonidine Good analgesic and sedative Beware of hypotension especially if other hypotensing agents on board eg spinal anaesthesia Eg 15µg q 15min IV, 2.5mg/week patch
  25. 25. Long acting analgesia
  26. 26. Long acting opioids
  27. 27. Fentanyl patch Ketamine infusion eg 0.3mg/kg/hour PCA eg fentanyl SC morphine eg palliative (NZ medical system resistant to use of SC fentanyl currently)
  28. 28. Procedural anaesthesia Current drug limits for RMOs is say 100 mcg fentanyl + 2 mg of midazolam RMOs currently are not allowed to use propofol or more than 30mg ketamine unsupervised (even though probably safer than midazolam and morphine) Pt who had 2 respiratory arrests in Xray after a shoulder reduction
  29. 29. Procedural Anaesthesia Ketamine + propofol = magic Ketamine is a excellent analgesic and patients (if you give it right) maintain their ABCs Downside: “Bad trips” = “emergence reactions” Vomiting Add propofol Anxiolytic Antiemetic = near perfect combo
  30. 30. Procedural Anaesthesia Still potential for ABC disaster and you need to have all your toys + drugs + skilled personnel for an RSI available
  31. 31. References Oxford league table of analgesics in acute pain http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Acutre v/Analgesics/Leagtab.html
  32. 32. Your stories Questions? Comments? Suggestions? chricres@gmail.com

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