Pain Management in the ED Elise O. Lovell, MD
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
Some specific analgesics
Ketorolac (Toradol)Cox-2 InhibitorsTramadol (Ultram)Propoxyphene (Darvon)Codeine/Hydrocodone/OxycodoneMeperidine (Demerol)Fentanyl (Sublimaze)MorphineHydromorphone (Dilaudid)
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 !!
Case 4
50 yo female, distal radius fracture, no reduction needed, in splint, ready for discharge.
PMH: negative, no allergy
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
COX-2 Inhibitors
Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Bextra)Efficacy similar to other NSAIDSImproved GI profile (maybe)Increased risk of MI and CVAAll NSAIDS with Renal, BP,GI effects, edema
COX-2 Inhibitors
Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Bextra)
Efficacy similar to other NSAIDS
Improved GI profile (maybe)
Increased risk of MI and CVA
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
Propoxyphene (Darvon)
Synthetic narcotic
In OD, expect seizures, also can cause cardiac toxicity (blocks), requires high doses of narcan to reverse
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
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
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
Ketamine, continued
Normal or increased muscle tone
Preserved airway reflexes
Analgesia, amnesia
Stable or increased BP and Pulse
Bronchodilator
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
Propofol (Diprivan)
Sedative hypnotic-NOT analgesicOnset 40 seconds, off in 5-10 minutesSide effects: Hypotension, Apnea, InfectionDecreases ICP, anti-emetic, anti-epilepticDecreased side effects with infusion rather than bolusDifferent dosing for induction vs. procedural sedation vs. maintenance
Propofol (Diprivan) Dosing
May add low dose fentanyl (1 mic/kg IV) as analgesic, and use lower propofol dosePediatrics- use 1 mg/kg IV“propofol syndrome” in kids seen in PICU-longer duration sedation (acidosis, hypotension, organ failure)
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)
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
Etomidate
Sedative hypnotic, NOT analgesicInduction dose 0.3 mg/kg IV push, use 0.15 mg/kg for procedural sedation Onset within one minute, off in about 10 minutesDecreases ICP and IOP Stable CV effectsCan cause myoclonus (not seizures), vomiting, respiratory depressionAdrenal suppression-consider alternative in sepsis
Take home points
Dose analgesics to effectiveness, not an arbitrary number of mgDose early, dose oftenBe proactive about offering analgesicsRemember the potency of DilaudidKetorolac is expensive Ibuprofen Etomidate and Propofol are NOT Analgesics
Propofol (Diprivan) dosing
Procedural sedation: usually slow push 1-1.5 mg/kg with repeated dosing of 0.5 mg/kg, duration 8-10 minutesInduction: 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